Optimizing visualization and ergonomics. - Academy of Laser Dentistry

The Official Journal of the Academy of Laser Dentistry 2007 • Vol. 15 No. 3 

Optimizing visualization and ergonomics. 

See the clinical review article on microscopy-assisted laser dentistry on page 122 

• Clinical / Scientific Review: Caries Detection 

• Clinical Review and Case Report: Implant Periapical 

Lesion Therapy and Guided Bone Regeneration 

• Case Reports: Treatment of Moderate Chronic 

Periodontitis and Subcrestal Tooth Fracture 

Academy of Laser Dentistry 

3300 University Drive, Suite 704 

Coral Springs, FL 33065

Journal of Laser Dentistry 

The official journal of the 


Editor in Chief 

John D.B. Featherstone, MSc, PhD 

San Francisco, CA jdbf@ucsf.edu 

Managing Editor 

Gail S. Siminovsky, CAE, Executive Director 

Coral Springs, FL siminovsky@laserdentistry.org 

Consulting Editor 

John G. Sulewski, MA 

Huntington Woods, MI john.sulewski@we-inc.com 

Associate Editors 

Donald J. Coluzzi, DDS 

Portola Valley, CA don@laser-dentistry.com 

Steven P.A. Parker, BDS, LDS RCS, MFGDP 

Harrogate, Great Britain 

thewholetooth@easynet.co.uk 

Editorial Board 


Gail S. Siminovsky, CAE 

John G. Sulewski, MA 

Donald J. Coluzzi, DDS 

Steven P.A. Parker, BDS, LDS RCS, MFGDP 

Alan J. Goldstein, DMD 

Donald E. Patthoff, DDS 

Peter Rechmann, Prof. Dr. med. dent. 

Publisher 

Max G. Moses 

Member Media 

1844 N. Larrabee 

Chicago, IL 60614 

312-296-7864 

Fax: 312-896-9119 

max@maxgmoses.com 

Design and Layout 

Diva Design 

2616 Missum Point 

San Marcos, TX 78666 

512-665-0544 

Fax: 512-392-2967 

kkolstedt@austin.rr.com 

Editorial Office 


Coral Springs, FL 33065 

954-346-3776 

Fax 954-757-2598 

www.laserdentistry.org 

laserexec@laserdentistry.org 

The Academy of Laser Dentistry is a not-for-profit 

organization qualifying under Section 501(c)(3) of 

the Internal Revenue Code. The Academy of Laser 

Dentistry is an international professional membership 

association of dental practitioners and supporting 

organizations dedicated to improving the 

health and well-being of patients through the 

proper use of laser technology. The Academy is 

dedicated to the advancement of knowledge, 

research and education and to the exchange of 

information relative to the art and science of the 

use of lasers in dentistry. The Academy endorses 

the Curriculum Guidelines and Standards for 

Dental Laser Education. 

Member American Association of Dental Editors 

TABLE OF CONTENTS 

EDITOR’S VIEW 

Optical Methods for the Enhancement of Dental Practice ..................116 


GUEST EDITORIAL 

The Transformative Dental Experience ........................................................118 

Alan J. Goldstein, DMD 

COVER FEATURE 

CLINICAL REVIEW 

Use of the Dental Operating Microscope 

in Laser Dentistry: Seeing the Light ..............................................................122 

Glenn A. van As, DMD 

CLINICAL/SCIENTIFIC REVIEW 

Detection of Caries by DIAGNOdent: 

Scientific Background and Performance ....................................................130 

Raimund Hibst, PhD 

Er:YAG Laser-Assisted Implant Periapical Lesion Therapy 

(IPL) and Guided Bone Regeneration (GBR) Technique: 

New Challenges and New Instrumentation ..............................................135 

Avi Reyhanian, DDS; Donald J. Coluzzi, DDS 

ADVANCED PROFICIENCY CASE STUDIES 

Introduction ..........................................................................................................142 

Nd:YAG Laser Use in Treatment of 

Moderate Chronic Periodontitis ....................................................................144 

Mary Lynn Smith, RDH 

Treatment of a Subcrestal Tooth Fracture with the Er:YAG Laser ........151 

Charles R. Hoopingarner, DDS 

R ESEARCH ABS TRA CTS 

Laser Bactericidal Effects on Intraoral Implants ........................................156 

The Journal of Laser Dentistry 

The mission of the Journal of Laser Dentistry is to provide a professional quarterly journal 

that helps to fulfill the goal of information dissemination by the Academy of Laser Dentistry. 

The purpose of the Journal of Laser Dentistry is to present information about the use of lasers 

in dentistry. All articles are peer-reviewed. Issues include manuscripts on current indications 

for uses of lasers for dental applications, clinical case studies, reviews of topics relevant to 

laser dentistry, research articles, clinical studies, research abstracts detailing the scientific 

basis for the safety and efficacy of the devices, and articles about future and experimental 

procedures. In addition, featured columnists offer clinical insights, and editorials describe 

personal viewpoints. 

JOUR NAL OF LASER DENTIS TRY | 2007 VOL 15, NO. 3 

115


116 


Optical Methods for the Enhancement of 

Dental Practice 

John D.B. Featherstone, MSc, PhD, San Francisco, California 

J Laser Dent 2007;15(3):116-117 

SYNOPSIS 

John Featherstone, editor-in-chief, describes some of the highlights of 

this issue of the Journal of Laser Dentistry, emphasizing the broad 

applications of optical technology in daily practice. 

The use of light technology in the 

practice of everyday clinical 

dentistry is not restricted simply to 

lasers. Clinicians have examined 

the tissues of the mouth by eye 

forever. The human eye is one of 

the best optical tools that we have. 

New optical tools are now available 

for the practitioner and additional 

new ones are on the horizon. These 

will be highlighted in future issues. 

What remains is to understand 

what these tools have to offer and 

to make the best use of them for 

the benefit of the patient. 

Microscopes have been used in 

laboratory settings and in clinical 

medicine for a long time. More 

recently the dental profession has 

started to embrace the use of 

microscopes on a routine basis, 

especially in endodontics. So why 

not for dentistry with lasers? In 

this issue the Academy of Laser 

Dentistry 2006 Leon Goldman 

awardee, Dr. Glenn van As, reviews 

the background and how the use of 

microscopes has revolutionized his 

daily practice. 

Until recently caries detection 

has been largely visual, tactile, and 

has relied on the use of radiography 

where the eye could not see. 

New tools are coming on the 

market to aid the clinician in the 

detection of carious lesions. Laser 

fluorescence is the science behind 

one such tool. Dr. Raimund Hibst, 

one of the scientists involved in the 

research that led to the practical 

use of this methodology, provides a 

review in this issue of the science, 

laboratory assessment, and clinical 

evaluation of one of these tools. 

Periodontal therapy can be 

enhanced by the use of lasers. As 

time goes on we are achieving a 

better understanding not only of 

the science behind the use of lasers 

for periodontal uses but also 

learning how better to use lasers in 

everyday practice. Several articles 

in this issue provide practical illustrations 

of the benefits of laser 

technology in this area of dentistry. 

The dentist and the hygienist can 

work closely together for the 

benefit of the patient. 

So what does all this mean? The 

standard of care in dental practice 

is evolving. Judicious use of optical 

technology in clinical practice 

requires ongoing education, sharing 

of science, practice, clinical studies, 

case reports, and most importantly 

the engaging of the brain before 

embarking on laser-assisted procedures. 

The Journal of Laser 

Dentistry offers a mix of science 

and practice, including clinical and 

laboratory studies, reviews, and 

case studies. It is over to the reader 

to make the best use of the information 

for their education and 

most importantly the better health 

of the patient. 

Finally, then, let us put this in 

perspective. In the guest editorial 

in this issue, Dr. Alan Goldstein 

addresses the philosophical issue 

that is generated by my statements 

in the preceding paragraph. He 

states “In my office, I take the position 

that our task is to make every 

patient experience transformative.” 

In order to do that we must truly 

understand what we are doing, 

what the likely outcomes are, and 

combine science, training, and 

experience together to this end. We 

must all be continual learners and 

work out how to apply our learning 

to whatever we do each day. 

Please enjoy this issue of the 

Journal. Feel free to e-mail me 

with suggestions, criticisms, or 

compliments at jdbf@ucsf.edu. 

AUTHOR BIOGRAPHY 

Dr. John D.B. Featherstone is 

Professor of Preventive and 

Restorative Dental Sciences and 

Interim Dean in the School of 

Dentistry at the University of 

California, San Francisco (UCSF). 

He has a Ph.D. in chemistry from 

the University of Wellington (New 

Zealand). His research over the 

past 33 years has covered several 

aspects of cariology (study of tooth 

decay) including fluoride mechanisms 

of action, de- and 

remineralization of the teeth, 

apatite chemistry, salivary dysfunction, 

caries (tooth decay) 

prevention, caries risk assessment, 

and laser effects on dental hard 

tissues with emphasis on caries 

prevention and early caries 

removal. He has won numerous 

national and international awards 

including the T.H. Maiman award 

for research in laser dentistry from 

the Academy of Laser Dentistry in 

2002, and the Norton Ross Award 

for Clinical Research from the 

American Dental Association in 

2007. In 2005 he was honored as 

the first lifetime honorary member 

of the Academy of Laser Dentistry. 

Dr. Featherstone has published 

Featherstone

Featherstone 


more than 200 papers. He is the 

editor-in-chief of the Journal of 

Laser Dentistry. 

Disclosure: Dr. Featherstone has no 

personal financial interest in any 

company relevant to the Academy of 

Laser Dentistry. He consults for, has 

consulted for, or has done research 

funded or supported by Arm & 

Hammer, Beecham, Cadbury, GSK, 

KaVo, NovaMin, Philips Oralcare, 

Procter & Gamble, OMNII Oral 

Pharmaceuticals, Oral-B, Wrigley, and 

the National Institutes of Health. ■■ 

Editorial Policy 

The Journal of Laser Dentistry is devoted to providing the Academy and its members with 

comprehensive clinical, didactic and research information about the safe and effective uses of 

lasers in dentistry. All statements of opinions and/or fact are published under the authority of 

the authors, including editorials and articles. The Academy is not responsible for the opinions 

expressed by the writers, editors or advertisers. The views are not to be accepted as the views 

of the Academy of Laser Dentistry unless such statements have been expressly adopted by the 

organization. Information on any research, clinical procedures or products may be obtained 

from the author. Comments concerning content may be directed to the Academy’s main office 

by e-mail to laserexec@laserdentistry.org 

Submissions 

We encourage prospective authors to follow JLD’s “Instructions to Authors” before submitting 

manuscripts. To obtain a copy, please go to our Web site www.laserdentistry.org/press.cfm. 

Please send manuscripts by e-mail to the Editor at jdbf@ucsf.edu. 

Disclosure Policy of Contributing Authors’ Commercial Relationships 

According to the Academy’s Conflict of Interest and Disclosure policy, authors of manuscripts 

for JLD are expected to disclose any economic support, personal interests, or potential bias 

that may be perceived as creating a conflict related to the material being published. 

Disclosure statements are printed at the end of the article following the author’s biography. 

This policy is intended to alert the audience to any potential bias or conflict so that readers 

may form their own judgments about the material being presented. 

Disclosure Statement for the Academy of Laser Dentistry 

The Academy of Laser Dentistry has no financial interest in any manufacturers or vendors of 

dental supplies. 

Reprint Permission Policy 

Written permission must be obtained to duplicate and/or distribute any portion of the Journal 

of Laser Dentistry. Reprints may be obtained directly from the Academy of Laser Dentistry 

provided that any appropriate fee is paid. 

Copyright 2007 Academy of Laser Dentistry. All rights reserved unless other ownership is indicated. If 

any omission or infringement of copyright has occurred through oversight, upon notification amendment 

will be made in a future issue. No part of this publication may be reproduced or transmitted in 

any fom or by any means, individually or by any means, without permission from the copyright holder. 

The Journal of the Academy of Laser Dentistry ISSN# 1935-2557. 

JLD is published quarterly and mailed nonprofit standard mail to all ALD members. Issues are 

also mailed to new member prospects and dentists requesting information on lasers in dentistry. 

Advertising Information and Rates 

Display rates are available at www.laserdentistry.org/press.cfm and/or supplied upon 

request. Insertion orders and materials should be sent to Bill Spilman, Innovative Media 

Solutions, P.O. Box 399, Oneida, IL 61467, 877-878-3260, fax: 309-483-2371, e-mail 

bill@innovativemediasolutions.com. For a copy of JLD Advertising Guidelines go to 

www.laserdentistry.org/press_advguide_policy.cfm. The cost for a classified ad in one issue is 

$50 for the first 25 words and $2.00 for each additional word beyond 25. ALD members 

receive a 20% discount. Payment must accompany ad copy and is payable to the Academy of 

Laser Dentistry in U.S. funds only. Classified advertising is not open to commercial enterprises. 

Companies are encouraged to contact Bill Spilman for information on display advertising 

specifications and rates. The Academy reserves the right to edit or refuse ads. 

Editor’s Note on Advertising: 

The Journal of Laser Dentistry currently accepts advertisements for different dental laser educational 

programs. Not all dental laser educational courses are recognized by the Academy of Laser Dentistry. 

ALD as an independent professional dental organization is concerned that courses meet the stringent 

guidelines following professional standards of education. Readers are advised to verify with ALD whether 

or not specific courses are recognized by the Academy of Laser Dentistry in their use of the Curriculum 

Guidelines and Standards for Dental Laser Education.


118 


The Transformative Dental Experience 

Alan J. Goldstein, DMD, New York, New York 


SYNOPSIS 

Dr. Goldstein, past president of the Academy of Laser Dentistry, high- 

lights how we can and should profoundly and beneficially affect our 

patients during our interactions with them. 

In times of change, learners inherit 

the Earth, while the learned find 

themselves beautifully equipped to 

deal with a world that no longer 

exists. 

— Eric Hoffer 

The skills and knowledge that 

created the problem will be insufficient 

in the development of its 

solution. 

— Albert Einstein 

The spring 2007 issue of the 

Journal of the New York State 

Academy of General Dentistry 

published an article by Dr. Robert 

Willis 1 that emphasized the role of 

emotions over logic as patients 

made decisions about proposed 

treatment plans. It is a perspective 

that has its roots all the way back 

to Dale Carnegie’s decades-long 

bestseller first published in 1936, 

How to Win Friends and Influence 

People. 2 But is Dr. Willis right? Is 

this emotional component valid or 

over-hyped? What are we, as scientists, 

researchers, and clinicians to 

believe in our statistically laden 

and evidence-based world? 

As well we might inquire 

whether this logic/emotion 

dichotomy is valid. I don’t think so. 

I believe it is only when we synthesize 

emotion and logic that we have 

the capacity to move people, to 

transform them. This is a perspective 

that is different from the 

teacher whose goal is to teach 

laser-tissue interaction to her 

students or from the practitioner 

whose goal is to fix teeth and eradicate 

periodontal disease. While 

these are all good things to achieve, 

essential things if you will, I want 

to achieve more. 

In my office, I take the position 

that our task is to make every 

patient experience transformative. 

I want our patients to be changed 

by their interaction with us. Some 

might consider it preposterous and 

grandiose, but I would happily 

extend this challenge to all of us in 

every activity we undertake, either 

as a scientist or clinician. I maintain 

that it is the only attitude to 

take if leadership is embodied in 

our work. If we are alive and open 

to the ever-expanding world before 

us, every interaction that has its 

beginning in the world of test 

tubes, microscopes, or humans has 

the capacity to be transformative. 

As scientists and clinicians we 

are both practitioners and learners. 

In the former sense we dispense 

knowledge and craft; in the latter 

we take it in. It is very difficult, 

probably impossible, to make the 

distinction between the learner and 

what it is that is learned – the 

scientist from the science or the 

clinician from clinical outcomes 

achieved. Sure, there is a great deal 

to be employed, integrated, and 

dispensed in our scientific community 

— skills, content, updating, and 

information-gathering strategies — 

and we are obligated to do the best 

we can. But I’d like to focus on the 

side that I think is most important 

in the transformational experience: 

learning. 

Learning has a vibrant and 

exploratory quality. Its root is 

education, a word that comes from 

the Latin verb educare, which 

means to lead. Truly learning is 

leading – not only leading others, 

but leading ourselves to new ways 

and seeing, knowing, and doing. 

Learning means going into 

uncharted territory, opening and 

reshaping knowledge. This of 

course requires both a questioning 

mind and a courageous spirit. What 

does this involve for us in the world 

of dentistry and laser technology? 

How do we use our learning to 

open new horizons in the care we 

provide, to explore new clinical 

applications while still appreciating 

the science that supports them, and 

to bridge new practice and established 

theory? In short, how do we 

create the transformative experience? 

Albert Einstein, whose life is 

explored in the revealing new biography 

by Walter Isaacson, 3 and to 

whose inquisitiveness and genius 

we owe the foundations of laser 

science and laser dentistry said, 

“The value of a college education 

[we might add professional education] 

is not the learning of many 

facts but the training of the mind 

to think.” Thinking is far more 

challenging and rewarding than 

simply performing. 

In our world of laser technology, 

we begin with valid scientific principles, 

ground them in sound 

clinical practice, apply our inquisitiveness 

to new techniques, and at 

the end of this process wind up 

with potential breakthroughs in 

patient care. Of course, one has to 

Goldstein

e radical to take the risks that our 

conservative profession says are 

beyond the bounds of our do-noharm 

charge. But risk-free and 

do-no-harm are not equivalents. No 

care is risk-free, and neither is life. 

We run risks when we invade teeth 

with a handpiece, we run risks 

when do a simple a procedure like 

a prophylaxis. Certainly even the 

most prudent in our profession 

would acknowledge that risks 

increase in direct proportion to our 

zeal to do good and the scope of our 

efforts. And yes, we can mitigate 

these risks with education, 

training, and experience. But risk 

cannot be eliminated, ever. Do 

nothing and the risk of malpractice 

looms large. 

There is irony here. Many 

colleagues, often those least 

familiar with the principles of laser 

technology, see our unique armamentarium 

through their own 

conservative, do-no-harm prism. A 

drill that creates micro (and not-somicro) 

fractures is seen as proper; 

while laser energy that creates 

small, easily restorable, virtually 

sterile cavities without fractures is 

seen as radical. It is language that 

has turned dentistry on its head. 

Goldstein 

This inversion of science extends to 

the discussion of laser technology 

for soft-tissue care. Excisional 

treatment is deemed conservative 

and appropriate, while care offered 

at the multiple-cell layer level — 

which has the added benefit of 

being bactericidal — is deemed 

radical and without value. Am I 

missing something? 

My point is that I sometimes see 

our profession as learned, in the 

sense described by Eric Hoffer 

above — and yet it often refuses to 

acknowledge that learning is the 

activity most urgently required. 

Confucius identified the first and 

essential virtue as courage. I have 

a feeling I know where he would 

come down on this question of 

whether every interaction is potentially, 

and optimally, transformative 

— and what it takes to achieve it. 


Born and raised in the Bronx, Dr. 

Alan Goldstein graduated from the 

City College of New York before 

receiving his dental degree from 

the University of Pennsylvania 

School of Dental Medicine in 1968. 

He is a frequent contributor to the 

dental literature as well as a 


lecturer in a variety of venues. He 

was certified as a Professional 

Coach in 2001 and often addresses 

audiences on topics of personal 

effectiveness, fulfillment, and leadership 

as well as dental practice 

management and use of lasers. He 

is a past president of the Academy 

of Laser Dentistry and a former 

editor of Wavelengths. He serves on 

the Dental Advisory Board of 

Dentistry Today and the Journal of 

Laser Dentistry. Dr. Goldstein may 

be contacted by e-mail at: 

llaama1@mindspring.com. 

Disclosure: Dr. Goldstein has 

provided educational services for a 

number of laser manufacturers and 

received honoraria for these services. 

Presently he has no commercial financial 

relationships. 

REFERENCES 

1. Willis R. What it takes to boost case 

acceptance. J N Y State Acad Gen 

Dent 2007 Spring:16-17. 

2. Carnegie D. How to win friends and 

influence people. New York: Simon & 

Schuster, Inc., 1936. 

3. Isaacson W. Einstein: His life and 

universe. New York: Simon & 

Schuster, Inc., 2007. ■■ 


119

Journal of Laser Dentistry: Guidelines for Authors 

The Academy of Laser Dentistry Welcomes Your Articles for Submission 

The Journal of Laser Dentistry publishes 

articles pertaining to the art, science, 

and practice of laser dentistry and 

other relevant light-based technologies. 

Articles may be scientific and clinical in 

nature discussing new techniques, 

research, and programs, or may be 

applications-oriented describing specific 

problems and solutions. While lasers 

are our preferred orientation, other 

high-technology articles, as well as 

insights into marketing, practice management, 

regulation, and other aspects 

of dentistry that may be of interest to 

the dental profession, may be appropriate. 

All articles are peer-reviewed prior 

to acceptance, modification, or rejection. 

These guidelines are designed to 

help potential authors in writing and 

submitting manuscripts to the Journal 

of Laser Dentistry, the official publication 

of the Academy of Laser Dentistry 

(ALD). Please follow these instructions 

carefully to expedite review and processing 

of your submission. Manuscripts 

that do not adhere to these instructions 

will not be accepted for consideration. 

The Academy of Laser Dentistry and the 

editors and publisher of the Journal of 

Laser Dentistry endorse the “Uniform 

Requirements of Manuscripts Submitted 

to Biomedical Journals” (www.icmje.org). 

The Journal reserves the right to revise 

or rescind these guidelines. 

Authors are advised to read the more 

comprehensive Guidelines for Authors 

and required forms available by mail or 

online at www.laserdentistry.org. 

Manuscript Eligibility 

Submitted manuscripts must be written 

clearly and concisely in American 

English and appropriate for a scholarly 

journal. Write in active voice and use 

declarative sentences. Manuscripts will 

be considered for publication on the condition 

that they have been submitted 

exclusively to the Journal, and have not 

been published or submitted for publication 

in any part or form in another publication 

of any type, professional or lay, or 

in any language elsewhere, and with the 

understanding that they will not be 

reprinted without written consent from 

both the managing editor and the author. 

Permissions 

Direct quotations of 100 or more words, 

and illustrations, figures, tables, or 

other materials (or adaptations thereof) 

that have appeared in copyrighted 

material or are in press must be accompanied 

by written permission for their 

use in the Journal of Laser Dentistry 

from the copyright owner and original 

author along with complete information 

regarding source, including (as applica- 

ble) author(s), title of article, title of 

journal or book, year, volume number, 

issue number, pages. Photographs of 

identifiable persons must be accompanied 

by valid signed releases indicating 

informed consent. When informed consent 

has been obtained from any 

patient, identifiable or not, it should be 

noted in the manuscript. The appropriate 

Permission Letters must be submitted 

with the manuscript. Suggested 

template letters are available online. 

Copyright 

All manuscript rights shall be transferred 

to the Journal of Laser Dentistry 

upon submission. Upon submission of 

the manuscript, authors agree to submit 

a completed Copyright Transfer 

Agreement form, available online. If the 

manuscript is rejected for publication, 

all copyrights will be retained by the 

author(s). 

Commercialism 

ALD members are interested in learning 

about new products and service 

offerings, however ALD stresses that 

submitted manuscripts should be educational 

in nature. The emphasis is on 

scientific research and sound clinical 

and practical advice, rather than promotion 

of a specific product or service. 

Disclosure of Commercial Relationships 

According to the Academy’s Conflict of 

Interest and Disclosure policy, manuscript 

authors and their institutions are 

expected to disclose any economic or 

financial support, as well as any personal, 

commercial, technological, academic, 

intellectual, professional, philosophical, 

political, or religious interests 

or potential bias that may be perceived 

as creating a conflict related to the 

material being published. Such conditions 

may include employment, consultancies, 

stock ownership or other equity 

interests, honoraria, stipends, paid 

expert testimony, patent ownership, 

patent licensing arrangements, royalties, 

or serving as an officer, director, or 

owner of a company whose products, or 

products of a competitor, are identified. 

Sources of support in the form of contracts, 

grants, equipment, drugs, material 

donations, clinical materials, special 

discounts or gifts, or other forms of support 

should be specified. The role of the 

study or manuscript sponsor(s), if any, 

are to be described. Disclosure statements 

are printed at the end of the article 

following the author’s biography. 

This policy is intended to alert the audience 

to any potential bias or conflict so 

that readers may form their own judgments 

about the material being pre- 

sented. Disclosure forms are to be 

signed by each author. Manuscripts will 

not be reviewed without the Journal 

having this form on file. 

The Academy of Laser Dentistry also 

requires that authors disclose whether 

any product discussed in their manuscript 

is unlabeled for the use discussed 

or is investigational. 

The Disclosure Statement form is 

available online and must be submitted 

with the manuscript. 

Manuscript Types 

Submissions to the Journal should be 

limited to one of the types indicated 

below. 

• Scientific / Technology / Clinical 

Review 

• Case Reports and Clinical Case 

Studies 

• Scientific / Clinical Research 

• Randomized Clinical Trials 

• Advances in Dental Products 

• Trends 

• Practice Management 

• Guest Editorials and Essays 

• Letters to the Editor 

• Book Reviews 

Manuscript Preparation and 

Submission 

Format 

All submitted manuscripts should be 

double-spaced, using 12 pt. font size 

with at least 6 mm between lines. 

Submit manuscripts in Microsoft Word 

(.doc), using either the Windows or 

Macintosh platform. Manuscripts must 

be submitted electronically in this format. 

Hard copy-only submissions will 

not be accepted. 

Unacceptable Formats 

The following submission formats are 

unacceptable and will be returned: 

• Manuscripts submitted in desktop 

publishing software 

• PowerPoint presentations 

• Any text files with embedded images 

• Images in lower than the minimum 

prescribed resolution. 

Manuscript Components 

Title Page 

The title page of the manuscript should 

include a concise and informative title 

of the article; the first name, middle initial(s), 

and last name of each author, 

along with the academic degree(s), professional 

title(s), and the name and 

location (city, state, zip code) of current 

institutional affiliation(s) and department(s). 

Authors who are private practitioners 

should identify their location 

(city, state, and country). Include all 

information in the title that will make

electronic retrieval of the article sensitive 

and specific. Titles of case studies 

should include the laser wavelength(s) 

and type(s) utilized for treatment (for 

example, “810-nm GaAlAs diode”). 

Identify the complete address, business 

and home telephone numbers, fax 

number, e-mail address, and Web site 

address (if any) for all authors. Identify 

one author as the corresponding author. 

Unless requested otherwise, the e-mail 

address is published in the Journal. 

Abstract 

A self-standing summary of the text of 

up to 250 words should precede the 

introduction. It should provide an accurate 

summary of the most significant 

points and be representative of the 

entire article’s content. Provide the context 

or background for the article, basic 

procedures, main findings and conclusions. 

Emphasize new or important 

aspects. Do not use abbreviations (other 

than standard units of measurement) or 

references in the abstract. 

Author(s) Biography 

Provide a brief, current biographical 

sketch of each author that includes professional 

education and professional 

affiliations. For authors who hold teaching 

positions, include the title, department, 

and school. For authors who are 

in federal service, include rank or title 

and station. 

References 

References are to be cited in the text by 

number in order of appearance, with 

the number appearing either as a 

superscript or in brackets. The reference 

list should appear at the end of the 

manuscript with references in order of 

first appearance in the text of the manuscript. 

The reference list must be 

typed double-spaced on a separate page 

and numbered in the same sequence as 

the reference citations appear in the 

text. Prior to submission, all references 

are to be properly prepared in the correct 

format, checked for completeness, 

carefully verified against their original 

documents, and checked for accurate 

correspondence between references 

cited in the text and listed in the 

References section. 

• For journal citations, include surnames 

and all initials of all authors, 

complete title of article, name of journal 

(abbreviated according to the U.S. 

National Library of Medicine 

(www.nlm.nih.gov/services/ 

lpabbrev.html), year of publication, 

volume, issue number, and complete 

inclusive page numbers. If abstracts 

are cited, add the abstract number 

after the page number. 

• For book citations, specify surnames 

and initials of all authors, chapter 

number and title (if applicable), edi- 

tors’ surnames and initials, book 

title, volume number (if applicable), 

edition number (if applicable), city 

and full name of publisher, year of 

publication, and inclusive page numbers 

of citation. 

• For government publications or bulletins, 

identify the author(s) (if given); 

title; department, bureau, agency, or 

office; the publication series, report, 

or monograph number; location of 

publisher; publisher; year of publication; 

and inclusive page numbers. 

• For articles published online but not 

yet in print, cite with the paper’s 

Digital Object Identifier (DOI) added 

to the end of the reference. 

• For Web citations, list the authors 

and titles if known, then the URL 

and date it was accessed. 

• For presentations, list the authors, 

title of presentation, indication that 

the reference is a lecture, name of 

conference or presentation venue, 

date, and location. 

Illustration Captions and Legends 

All illustrations must be accompanied by 

individual explanatory captions which 

should be typed double-spaced on a separate 

page with Arabic numerals corresponding 

to their respective illustration. 

Tables 

Tables must be typewritten doublespaced, 

including column heads, data, 

and footnotes, and submitted on separate 

pages. The tables are to be cited in 

the text and numbered consecutively in 

Arabic numerals in the order of their 

appearance in the text. Provide a concise 

title for each table that highlights 

the key result. 

Illustrations 

Illustrations include photographs, radiographs, 

micrographs, charts, graphs, 

and maps. Each should be numbered and 

cited in the text in the order of appearance 

and be accompanied by explanatory 

captions. Do not embed figures within 

the manuscript text. Each figure and 

table should be no larger than 8-1/2 x 11 

inches. Digital files must measure at 

Illustration 

Type 

least 5 inches (127 mm) in width. The 

image must be submitted in the size it 

will be printed, or larger. Illustrations 

are to augment, not repeat, material in 

the text. Graphs must not repeat data 

presented in tables. Clinical photographs 

must comply with ALD’s Guidelines for 

Clinical Photography, available online. 

Authors are to certify in a cover letter 

that digitized illustrations accurately 

represent the original data, condition, or 

image and are not electronically edited. 

Publisher and Copyright Holder 

The Journal of Laser Dentistry is published 

by Max G. Moses, Member 

Media, 1844 N. Larrabee, Chicago, IL 

60614, Telephone: (312) 296-7864; Fax: 

(312) 896-9119. The Journal of Laser 

Dentistry is copyrighted by The 

Academy of Laser Dentistry, 3300 

University Drive, Suite 704, Coral 

Springs, FL 33065, Telephone: (954) 

346-3776; Fax: (954) 757-2598. 

Articles, Questions, Ideas 

Questions about clinical cases, scientific 

research, or ideas for other articles may 

be directed to John D.B. Featherstone, 

Editor-in-Chief, by e-mail: jdbf@ucsf.edu. 

Submission of Files 

by E-mail: 

Send your completed files by e-mail 

(files up to 10 MB are acceptable). If 

files are larger than 10 MB, they may 

be compressed or sent as more than one 

file, with appropriate labels. Files 

should be submitted to: 

John D.B. Featherstone, Editor-in-Chief 

by e-mail: jdbf@ucsf.edu. 

By Federal Express or Other 

Insured Courier: 

If using a courier, please send the file as 

a CD-ROM, include a hard copy of your 

manuscript and also send a verification 

by e-mail to Gail Siminovsky 

(laserexec@laserdentistry.org). 

Gail Siminovsky 



Coral Springs, FL 33065 

Phone: (954) 346-3776. 

Summary of Illustration Types and Specifications 

Definition and Examples 

Preferred 

Format 

Required 

Resolution 

Line Art and Black and white graphic with no 

EPS or JPG 1200 DPI 

Vector Graphics shading (e.g., graphs, charts, maps) 

Halftone Art 

Combination 

Art 

Photographs, drawings, or painting 

with fine shading (e.g., radiographs, 

micrographs with scale 

bars, intraoral photographs) 

Combination of halftone and line 

art (e.g., halftones containing 

line drawing, extensive lettering, 

color diagrams) 

TIFF or 

JPG 

300 DPI (black & 

white) 

600 DPI (color) 

EPS or JPG 1200 DPI


122 

COVER FEATURE 

Use of the Dental Operating Microscope 

in Laser Dentistry: Seeing the Light 

Glenn A. van As, DMD, North Vancouver, British Columbia, Canada 


SYNOPSIS 

Dr Van As was the recipient of the Leon Goldman Award for clinical 

excellence in laser dentistry in 2006. This article reviews his 

pioneering work using microscopy-assisted laser dentistry. 

INTRODUCTION 

The virtue of high levels of magnification 

in the medical field had been 

understood for many decades. 1-7 In 

1981, Apotheker introduced an 

operating microscope into dentistry, 

although it offered only a single 

level of magnification and could be 

used only in a standing position. 8 

In the late 1980s and early 

1990s, endodontists began to 

promote the dental operating 

microscope (D.O.M.) for its value in 

standard endodontic therapy and 

for the improvements in outcome of 

both nonsurgical retreatments and 

for surgical cases. 9-24 

At the same time, periodontists 

utilized the D.O.M. along with their 

microsurgical armamentarium, 

realizing reductions in postoperative 

pain and quicker healing. 25-31 

The use of lower-power telescopic 

loupes became more of the 

norm for all of dentistry during 

the mid-to-late 1990s. 32-33 With 

better understanding of the role 

and value of magnification, many 

practitioners purchased a higherpower 

set of loupes along with an 

illuminating headlight. As the 

present decade has progressed, 

the greatest increase in new users 

of the D.O.M. has been from those 

clinicians who routinely used 

loupes. In fact, in 2001, the 

author coined the term “magnification 

continuum” to describe the 

Figure 1: View of a microscope-centered 

dental operatory 

Figure 2: Neutral and balanced ergonomics 

of the author at the microscope 

ever-increasing powers of magnification 

being used in dentistry. 34 

The use of the operating microscope 

for both diagnosis (new 

patient examinations, earlier 

visualization of decay and 

ABSTRACT 

This article discusses the history 

and role of the dental operating 

microscope in dentistry. The 

microscope has become a standard 

part of the endodontic 

armamentarium since the 1980s 

as practitioners recognized the 

value of improved visual acuity 

through enhanced magnification 

and illumination. Benefits of the 

dental operating microscope 

including improvements in treatment 

outcomes, ergonomics, 

documentation, and communication 

are described. The 

importance of high levels of 

magnification for hard tissue laser 

dentistry are emphasized and 

detailed as this discipline, like 

endodontics, is also largely reliant 

on nontactile information for clinical 

success. 

cracks 35 ) and treatment (including 

laser dentistry) has become more 

accepted (Figure 1). 36-51 

This article examines the ability 

of the microscope to provide 

improvement in visual acuity and 

the effect that high levels of 

enhanced magnification and illumination 

can have on improving the 

quality of laser dentistry that is 

provided. 

BENEFITS OF MICRO- 

SCOPE-CENTERED 

P R A CTICES 

When used routinely for all aspects 

of dentistry, the microscope has 

four basic advantages: 

1. Improved precision of treatment 

2. Enhanced ergonomics (Figure 2) 

3. Ability to capture digital documentation 

(Figure 3) 

4. Enhanced communication 

through integrated video. 

van As

Figure 3: Illustration of the convenient 

arrangement of video camera on the left 

and a digital, single lens reflex camera 

(Nikon D70) on the right of the scope 

1. Improved Precision of 

Treatment 

The visual information provided by 

the operating microscope is in fact 

not indicative of the magnification 

that is being employed. The actual 

amount of visual information is the 

area of view through the scope and 

is therefore the product of the horizontal 

times the vertical number of 

pixels. Therefore, the clinician 

using the 2X magnification power 

of entry-level loupes sees approximately 

4 times the visual 

information of a dentist not using 

any magnification (unaided eye). 

Likewise, 3X loupes provide 9 times 

the visual information of the 

unmagnified view and more than 

double the view of the 2X set. Table 

1 summarizes the relative advantages 

of a variety of magnifications. 

The author uses his microscope 

typically at 10X magnification 

which provides 100X the amount of 

visual information compared to the 

unaided eye view. This is 25 times 

the information from 2X loupes and 

more than 10 times as that seen 

with 3X. 

Carr 52 reported that the unaided 

human eye has the inherent ability 

to resolve or distinguish two separate 

lines or entities that are at 

least 200 µm or 0.2 mm apart. If 

the lines are closer together, then 

even 20/20 unmagnified vision will 

van As 

not allow the 

clinician to 

resolve them as 

two separate 

entities and the 

objects will 

appear as one. 

Thus with 

magnification 

the resolution of 

the human eye 

improves 

dramatically 

(Table 2). 

Baldissara et 

al. 53 showed that 

the experienced 

clinician, when 

using a sharp, 

new explorer, 

can feel 

marginal gaps of 

around 36 µm. 

Thus, when 

COVER FEATURE 

Table 1: Comparison of Unaided Eye, 2X Loupes, and Other Levels of 

Magnification 

Magnification Visual Information (VI) 

VI Compared 

to 2X Loupes 

Unaided eye 1X 1/4 

2X loupes 4X Even = 1 

3X loupes 9X 2.25 

4X loupes 16X 4 

6X microscope 36X 9 



Table 2: Resolution vs. Assessment Method 

Assessment Method Magnification Resolution 

(µm) 

Resolution 

(mm) 

Unaided eye 1X 200 0.2 

Low-power loupes 2X 100 0.1 

Medium-power loupes 4X 50 0.05 

Sharp explorer NA 36 0.036 

Low-magnification microscope 6X 36 0.036 

Medium-magnification microscope 10X 20 0.02 

High-magnification microscope 20X 10 0.01 

Figure 4: Views of the same tooth area showing the effect of the 

magnification range of a typical microscope 


123


124 

COVER FEATURE 

magnification is beyond 6X power, 

the effectiveness of tactile means of 

inspection with an explorer significantly 

decreases. Many clinicians 

using a microscope now rely on 

visual rather than tactile means of 

discovery as their motor skills 

improve during the learning curve. 

The increased amount of information 

provided by the microscope 

offers some challenges. As the 

magnification increases, the depth 

and diameter of the field of view in 

the operating field decreases. At 

higher magnification, there is an 

increased demand for improved 

control of the micromotor muscles 

and joints (fingers and wrists) that 

can require stabilization of the 

gross motor joints (elbow and 

shoulder) with micro-surgeon 

chairs. Tibbets and Shanelec 54 

reported the medical literature 

showed that the clinician not using 

magnification made movements 

that were 1-2 mm at a time. At 

microscope levels of 20X magnification, 

the refinement in movements 

can be as little as 10-20 µm (10- 

20/1000ths of a millimeter) at a 

time. It is useful therefore to note 

that the limitation to precision of 

treatment is not in the hands but 

in the eyes. 

Impact of Improved Visual Acuity 

in Laser Dentistry 

The ability to carefully evaluate 

laser-tissue interaction at high 

magnification is important in many 

areas of laser dentistry. The microscope 

offers improved visual acuity 

through its enhancements in 

magnification (Figure 4) and coaxial, 

shadow-free illumination, 

and these properties can be of 

tremendous benefit during both 

soft tissue and hard tissue ablation 

procedures. 

Soft Tissue Laser Procedures and 

the Dental Operating Microscope 

The microscope can be especially 

effective for clinicians using laser 

wavelengths with small-diameter 

flexible optic fibers for soft tissue 

Figure 5: Sequence showing the benefit of using magnification 

Figure 5a: Preoperative view of maxillary 

incisors prior to veneer preps 

Figure 5b: Veneer preps done 

Figure 5c: Diode laser used to trough 

around margin 

procedures, such as with potassium 

titanyl phosphate (KTP), diode, and 

Nd:YAG lasers. For example, using 

a laser to trough around subgingival 

crown preparations can be 

frustrating because dragging the 

glass tip through inflamed tissue 

creates more bleeding. A 300micron 

fiber, which is close to the 

resolution of the human eye, must 

be accurately placed 1 mm or so 

into the sulcus to distend it, not to 

deepen it or to remove the papilla. 

The ability to closely watch the 

laser-tissue interaction is important 

to prevent excessive heat, 

while accurately aiming the endcutting 

fiber at the target tissue. 

The magnified view should prevent 

tissue charring, and thus decrease 

any postoperative discomfort for 

the patient (Figures 5a-5f). 

Excisional or incisional surgical 

procedures using small optic 

Figure 5d: High magnification of 

completed trough 

Figure 5e: Veneer impression 

Figure 5f: Tissue health at 2 weeks 

Figure 5g: Postoperative result 

contact fibers can be performed 

with added precision when viewed 

through the D.O.M. The clinician 

can easily visualize exactly when 

all tissue fibers have been ablated, 

reducing the need for retreatment 

due to relapse. 

In microscope-assisted noncon- 

van As

Figure 6: Examples of procedures that benefit from observation by magnification 

Figure 6a: Preoperative view of lower 

second molar 

Figure 6b: Sinus tract on buccal aspect 

tact soft tissue ablation, the clinician 

can keep the laser power 

settings lower and avoid iatrogenic 

damage to nontarget adjacent 

tissues. Magnification provides 

another advantage when the practitioner, 

using either erbium or 

carbon dioxide laser energy, is 

trying to avoid accidental interaction 

with tooth structure or bone. 

Other noncontact procedures, 

such as aphthous ulcer desensitization, 

hemostasis of extraction sites, 

and treatment of hemangiomas, 

can benefit from the visual acuity 

offered by magnification. Examples 

are shown in Figures 6a-6f. 

The erbium laser wavelengths 

(Er:YAG, Er,Cr:YSGG) may be used 

in contact or noncontact mode for 

soft tissue procedures. Using the 

noncontact mode can help to limit 

the inherent weakness of the 

erbium energy to adequately coagulate. 

The noncontact “plasty” or 

shaving down of tissue that is 

possible with the chisel or large 

footprint Er:YAG tips, when used 

in conjunction with the microscope 

van As 

Figure 6c: Extraction complete 

Figure 6d: Hemostasis by diode laser 

treatment 

Figure 7a: Noncontact Er:YAG frenectomy. 

Note early charring before adjusting 

power settings 

Figure 7b: High-magnification view of 

frenectomy. Note lack of hemorrhage in 

noncontact mode 

COVER FEATURE 

Figure 6e: Hemostatic laser-induced clot 

viewed at low magnification 

Figure 6f: Clot induced by diode laser 

viewed at high magnification 

Figure 7: Examples of Er:YAG or Er, Cr:YSGG laser procedures that can be better carried 

out under magnification 

Figure 7c: Noncontact “plasty” of epulis on 

maxillary lip. Note “flash” at ablation site 

Figure 7d: High-magnification view of 

frenectomy after periosteum is “scored” 

with an Er:YAG laser 


125


126 

COVER FEATURE 

Figure 8: Views relating to cavity preparation and restorations illustrating the benefits of using magnification 

Figure 8a: Preoperative interproximal decay 

Figure 8b: Decay visible on distal aspect 

of first primary molar 

at high magnification, is a 

wonderful technique for treating 

epulis and tissue tags, as well as in 

the creation of ovate pontics for 

fixed bridges where the tissue can 

be “melted” away (Figures 7a-7d). 

Hard Tissue Laser Ablation and the 

Operating Microscope 

Leknius and Geissberger 55 as well 

as Zaugg et al. 56 demonstrated that, 

when magnification was incorporated, 

procedural errors in 

restorative treatment decreased 

significantly. In the latter study, 

the use of a microscope resulted in 

fewer errors than loupes. Utilizing 

conventional instruments, the clinician 

can rely upon tactile means 

from burs or hand instruments to 

determine when the carious lesion 

is fully excavated or when old 

restorations have been completely 

removed. These same tactile 

methods become more unreliable in 

hard tissue laser dentistry where 

so much of the evaluation of the 

laser-tissue interface is based on 

visual cues. Caries detection dyes 

Figure 8c: High magnification shows 

decay still visible on facial wall of box 

Figure 8d: Preparations completed 

are not easy to use and can produce 

false readings with hard tissue 

laser preparations (Figures 8a-8f). 

Moreover, erbium lasers can use 

both contact tips (where the actual 

distance for effective ablation is 0.5 

- 1.5 mm from the surface) and 

noncontact delivery systems, and it 

is difficult to “feel” the ablation 

process. Therefore the use of high 

magnification is essential to determine 

when the preparation is 

complete. 

There are several more reasons 

to employ magnification for 

restorative procedures. A large 

amount of water is needed for effective 

and safe hard tissue ablation, 

but that amount of water can 

obscure good visualization. Where 

rigid contact tips are used to 

deliver laser energy, their clear 

color makes them difficult to see. 

They must have a nonchipped 

surface, and be held at the proper 

working distance from the target 

tissue, without tactile feedback. 

This optimum distance can vary 

with different instruments, but 

Figure 8e: Restorations finished 

ablation efficiency will significantly 

decrease as the delivery system is 

placed farther from the tooth. If the 

laser tip is brought into direct 

contact with the surface the cutting 

efficiency decreases, and the water 

flow is not able to wash away ablation 

byproducts and cool the tissue. 

Charring and patient sensitivity 

can occur. Enamel bevels for Class 

III, IV, and V restorations require 

the clinician to “scrape” or alter the 

ablated enamel prior to acid 

etching. High magnification with 

the operating microscope shows 

that enamel bevels have many 

loose rods which, if not altered with 

an instrument (hatchet or spoon, 

air abrasion or diamond bur), will 

yield significantly lower bond 

strength compared to bur-cut 

enamel. The fragments of enamel 

that are scraped off are easily 

visible under high magnification. 

The operating microscope is also 

an instrumental piece of the armamentarium 

for the ablation of bone. 

To prevent plucking or iatrogenic 

notching, it is best to use lower 

settings (1.5 - 3 Watts, for 

Figure 9: Laser beginning closed flap 

osseous contouring 

van As

Figure 10: Safety filter for use with 

various lasers 

Figure 10a: Nd:YAG (1064 nm) and 

erbium (2780-2940 nm) laser filter 

Figure 10b: Placing a diode (800-830 

nm) laser filter in the microscope 

example), a noncontact mode, and a 

high water flow to prevent charring 

and necrosis. The amount of water 

and slight bleeding can obscure 

visibility, so the ability to increase 

the magnification during the procedure 

is imperative to success. 

Osseous crown lengthening to 

gain or re-establish biologic width 

can be performed with erbium 

lasers. The microscope is especially 

useful for closed-flap procedures so 

that the clinician can more accurately 

direct the laser energy and 

avoid iatrogenic troughing of the 

bone. Figure 9 shows the laser 

beginning closed-flap osseous 

contouring. 

It is therefore very beneficial for 

van As 

magnification to be used for many 

aspects of hard tissue laser 

dentistry. The higher the level of 

magnification used, the greater the 

ability of the dentist to directly 

view the laser-tissue interaction 

and to use the lowest possible 

energy and power to complete the 

procedure. This ultimately 

produces less patient sensitivity 

and better tissue health. 

Laser Safety 

Safety is of paramount importance 

to laser practitioners whether they 

are using no magnification, telescopic 

loupes, or higher levels of 

magnification. All dental operating 

microscopes have holders that 

accept wavelength filters for eye 

protection. As usual, the laser 

safety officer must ensure that the 

appropriate filter is in place, and 

the user must be sure to make 

close eye contact with the oculars 

to avoid the possibility of irradiation 

by accidental stray light. 

Assistants and patients must wear 

appropriate eye protection. Figure 

10a shows a typical erbium laser 

filter and Figure 10b shows a filter 

being placed into the microscope. 

2. Improved Ergonomics 

The operating microscope allows 

for the dentist to sit with an 

upright, neutral, and balanced 

posture (Figure 2). This neutral 

and balanced posture obtainable 

with the D.O.M. has been discussed 

as being helpful in preventing 

ergonomic issues that plague so 

many dentists and seem to be an 

occupational hazard. 57-60 

3. Ability to Capture Digital 

Documentation 

The D.O.M. can be a beneficial 

addition in documenting a clinical 

case, especially because of the 

detailed image (Figure 3), whether 

still or video. Carr, 61 Behle, 62 and 

van As 63-64 have written articles 

discussing the merits of digital 

documentation with the D.O.M. and 

the advantages of doing so. 

COVER FEATURE 

4. Enhanced Communication 

through Integrated Video 

Dentists who have added video 

capability to the microscope have 

found it useful in providing information 

to both patients and to 

auxiliaries since they can observe 

treatment in real time. 65 Clinicians 

have found that the images from 

the operating scopes are a benefit 

to educating their patients about 

treatment needs and help in 

persuading patients to accept treatment 

plans. 

The use of video transmitted to 

different monitors in the operatory 

has initiated the possibility of 

working solely from a monitor, a 

method some surgeons now employ. 

The next improvement will be the 

development of three-dimensional 

displays. 65 

CONCLUSION 

The operating microscope used for 

laser dentistry provides benefits for 

any clinician. The advantages are 

improved precision, improved 

ergonomics, ease of documentation, 

and the ability to more fully 

communicate with patients, staff, 

and colleagues. Practitioners using 

the combination of the dental operating 

microscope and lasers have 

found that the two technologies 

work well in tandem and improve 

not only the treatment outcome but 

the enjoyment of providing it. 


Dr. Glenn A. van As is a 1987 graduate 

of the University of British 

Columbia Faculty of Dentistry who 

maintains a full-time private dental 

practice in North Vancouver, British 

Columbia, Canada. His areas of 

interest and expertise involve the 

utilization of the dental operating 

microscope for all of his clinical 

dentistry and in the use of multiple 

wavelengths of hard and soft tissue 

lasers for many procedures. Since 

1999, he has lectured more than 

200 times internationally, provided 

hands-on workshops, and published 

internationally on the value of 


127


128 

COVER FEATURE 

multiple wavelengths of lasers and 

practicing with the high magnifications 

obtainable with the dental 

operating microscope. Dr. van As is 

a member of the British Columbia 

Dental Association, the Canadian 

Dental Association, the Academy of 

Microscope Enhanced Dentistry 

(AMED), and the Academy of Laser 

Dentistry (ALD). He has obtained 

both Standard and Advanced 

Proficiency in laser usage from the 

Academy of Laser Dentistry, and 

was distinguished with the Leon 

Goldman award for clinical excellence 

in the field of laser dentistry 

in 2006. In addition, Glenn is a 

founding member of the Academy of 

Microscope Enhanced Dentistry, 

and in 2004-2005 served as the 

second president of the group 

(www.microscopedentistry.com). Dr. 

van As may be contacted by e-mail 

at glennvanas@shaw.ca. 

Disclosure: Dr. van As receives honoraria 

for lectures from the Global 

Surgical Corporation on microscopes, 

from HOYA ConBio on lasers, and 

from Ivoclar on lasers. 

REFERENCES 

1. Nylén CO. The microscope in aural 

surgery, its first use and later development. 

Acta Otolaryngol 

1954;Suppl 116:226-240. 

2. Jacobsen JH II, Suarez EL. 

Microsurgery in anastomosis of 

small vessels. Surg Forum 

1960;11:243-245. 

3. Harms H, Mackensen G. Ocular 

surgery under the microscope. 

Chicago: Yearbook Medical 

Publishers, Inc., 1967. 

4. Dohlman GF. Carl Olof Nylén and 

the birth of the otomicroscope and 

microsurgery. Arch Otolaryngol 

1969;90(6):813-817. 

5. Klopper PJ. Microsurgery and 

wound healing. In: Lie TS, editor. 

Microsugery. Proceedings of the 5th 

International Congress of the 

International Microsurgical Society, 

Bonn, October 4-7, 1978. 

Amsterdam: Excerpta Medica, 

International Congress Series No. 

465, 1979:280-282. 

6. Banowsky L. A review of optical 

magnification in urological surgery. 

Chapter 13 in Silber SJ, editor. 

Microsurgery. Baltimore: Williams 

and Wilkins, 1979:443-465. 

7. Barraquer JL. The history of the 

microscope in ocular surgery. J 

Microsurg 1980;1(4):288-289. 

8. Apotheker H, Jako GJ. A microscope 

for use in dentistry. J Micosurg 

1981;3(1):7-10. 

9. Carr GB. Microscopes in endodontics. 

J Calif Dent Assoc 

1992;20(11):55-61. 

10. Carr GB. Common errors in periradicular 

surgery. Endod Rep 

1993;8(1):12-18. 

11. Pecora G, Andreana S. Use of dental 

operating microscope in endodontic 

surgery. Oral Surg Oral Med Oral 

Pathol 1993;75(6):751-758. 

12. Ruddle CJ. Endodontic perforation 

repair: Using the surgical operating 

microscope. Dent Today 

1994;13(5):48, 50, 52-53. 

13. Feldman M. Microscopic surgical 

endodontics. N Y State Dent J 

1994;60(8):43-45. 

14. Mounce RE. Surgical operating 

microscope in endodontics: The 

paradigm shift. Gen Dent 

1995;43(4):346-349. 

15. Ruddle CJ. Nonsurgical endodontic 

retreatment. J Calif Dent Assoc 

1997;25(11): 769-771, 773-775, 777, 

779-786, 788-799. 

16. Stropko JJ. Canal morphology of 

maxillary molars: Clinical observations 

of canal configurations. J 

Endod 1999;25(6):446-450. 

17. de Carvalho MC, Zuolo ML. Orifice 

locating with a microscope. J Endod 

2000;26(9):532-534. 

18. Sempira HN, Hartwell GR. 

Frequency of second mesiobuccal 

canals in maxillary molars as determined 

by use of an operating 

microscope: A clinical study. J 

Endod 2000;26(11):673-674. 

19. Görduysus MO, Görduysus M, 

Friedman S. Operating microscope 

improves negotiation of second 

mesiobuccal canals in maxillary 

molars. J Endod 2001;27(11):683-686. 

20. Buhrley LJ, Barrows MJ, BeGole 

EA, Wenckus CS. Effect of magnification 

on locating the MB2 canal in 

maxillary molars. J Endod 

2002;28(4):324-327. 

21. Schwarze T, Baethge C, Stecher T, 

Geurtsen W. Identification of second 

canals in the mesiobuccal root of 

maxillary first and second molars 

using magnifying loupes or an operating 

microscope. Aust Endod J 

2002;28(2):57-60. 

22. Coutinho Filho T, La Cerda RS, 

Gurgel Filho ED, de Deus GA, 

Magalhães KM. The influence of the 

surgical operating microscope in 

locating the mesiolingual canal 

orifice: A laboratory analysis. Braz 

Oral Res 2006;20(1):59-63. 

23. Tsesis I, Rosen E, Schwartz-Arad D, 

Fuss Z. Retrospective evaluation of 

surgical endodontic treatment: 

Traditional versus modern technique. 

J Endod 2006;32(5):412-416. 

24. Schirrmeister JF, Hermanns P, 

Meyer KM, Goetz F, Hellwig E. 

Detectability of residual Epiphany 

and gutta-percha after root canal 

retreatment using a dental operating 

microscope and radiographs – 

An ex vivo study. Int Endod J 

2006;39(7):558-565. 

25. Shanelec DA. Current trends in soft 

tissue. J Calif Dent Assoc 

1991;19(12):57-60. 

26. Tibbets LS, Shanelec DA. An 

overview of periodontal microsurgery. 

Current Opin Periodontol 

1994:187-193. 

27. Shanelec DA, Tibbetts LS. 

Periodontal microsurgery. 

Periodontal Insights 1994;1(2):4-7. 

28. Michaelides PL. Use of the operating 

microscope in dentistry. J 

Calif Dent Assoc 1996;24(6):45-50. 

29. Shanelec DA, Tibbetts LS. A 

perspective on the future of periodontal 

microsurgery. 

Periodontology 2000 1996;11:58-64. 

30. Tibbetts LS, Shanelec D. Current 

status of periodontal microsurgery. 

Curr Opin Periodontol 1996;3:118- 

125. 

31. Belcher JM. A perspective on periodontal 

microsurgery. Int J 

Periodontics Restorative Dent 

2001;21(2):191-196. 

van As

32. Shanelec DA. Optical principles of 

loupes. J Calif Dent Assoc 

1992;20(11):25-32. 

33. Strassler HE, Syme SE, Serio F, 

Kaim JM. Enhanced visualization 

during dental practice using magnification 

systems. Compend Contin 

Educ Dent 1998;19(6):595-596, 598, 

600, 602, 604, 606, 608, 610-611, 

quiz 12. Erratum in: Compend 

Contin Educ Dent 1998;19(9):894. 

34. van As G. Magnification and the 

alternatives for microdentistry. 

Compend Contin Educ Dent 

2001;22(11A):1008-1012, 1014-1016. 

35. Clark DJ, Sheets CG, Paquette JM. 

Definitive diagnosis of early 

enamel and dentin cracks based on 

microscopic evaluation. J Esthet 

Restor Dent 2003;15(7):391-401, 

discussion 401. 

36. Martignoni M, Schönenberger A. 

Precision fixed prosthodontics: 

Clinical and laboratory aspects. 

Chicago: Quintessence Publishing 

Co. Inc., 1990. 

37. Friedman MJ, Landesman HM. 

Microscope-assisted precision 

dentistry – Advancing excellence in 

restorative dentistry. Contemp 

Esthetics Restorative Pract 

1997;1(1):45-49. 

38. Sheets CG, Paquette JM. Enhancing 

precision through magnification. 

Dent Today 1998;17(1):44, 46, 48-49. 

39. Piontkowski PK. The renaissance of 

dentistry: An introduction to the 

surgical microscope. Dent Today 

1998;17(6):82-87. 

40. Sheets CG, Paquette JM. The magic 

of magnification. Dent Today 

1998;17(12):61-67. 

41. Cruci P. An operating microscope in 

general dental practice. Dent Pract 

1999:37(9):1, 4-5. 

42. Friedman M, Mora AF, Schmidt R. 

Microscope-assisted precision 

dentistry. Compend Contin Educ 

Dent 1999;20(8):723-726, 728, 730- 

731, 735-736, quiz 737. 

van As 

43. Paquette JM. The clinical microscope: 

Making excellence easier. 

Contemp Esthetics Restorative Pract 

1999;3(9):12-20. 

44. van As GA. Using the surgical operating 

microscope in general practice. 

Contemp Esthetics Restorative Pract 

2000;4(1):34, 36-40. 

45. van As GA. The role of the dental 

operating microscope in fixed 

prosthodontics. Oral Health 

2002;92(6):11-14, 17-20, 23, 25. 

46. van As GA. The use of extreme 

magnification in fixed prosthodontics. 

Dent Today 2003;22(6):93-99. 

47. Christensen GJ. Magnification in 

dentistry: Useful tool or another 

gimmick? J Am Dent Assoc 

2003;134(12):1647-1650. 

48. Clark DJ. Microscope-enhanced 

aesthetic dentistry. Dent Today 

2004;23(11):96, 98-101. 

49. Garcia A. Dental magnification: A 

clear view of the present and a 

close-up view of the future. 

Compend Contin Educ Dent 

2005;26(6A Suppl):459-463. 

50. Clark DJ. The big push to clinical 

microscopes for esthetic dentistry. 

Contemp Esthetics Restor Pract 

2005;9(11):30-33. 

51. Clark DJ, Kim J. Optimizing gingival 

esthetics: A microscopic perspective. 

Oral Health 2006;96(4):116-118, 121- 

122, 124-126. 

52. Carr GB. Magnification and illumination 

in endodontics. In: Hardin 

JF, editor. Clark’s Clinical Dentistry. 

New York: Mosby, 1998;4:1-14. 

53. Baldissara P, Baldissara S, Scotti R. 

Reliability of tactile perception 

using sharp and dull explorers in 

marginal opening identification. Int 

J Prosthodont 1998;11(6):591-594. 

54. Tibbets LS, Shanelec D. Periodontal 

microsurgery. Dent Clin North Am 

1998;42(2):339-359. 

55. Leknius C, Geissberger M. The 

effect of magnification on the 

COVER FEATURE 

performance of fixed prosthodontic 

procedures. J Calif Dent Assoc 

1995;23(12):66-70. 

56. Zaugg B, Stassinakis A, Hotz P. 

Einfluss von vergrösserungshilfen 

auf die erkennung nachgestellter 

präparations- und füllungsfehler 

[Influence of magnification tools on 

the recognition of simulated preparation 

and filling errors]. Schweiz 

Monatsschr Zahnmed 

2004;114(9):890-896. 

57. Lunn R, Sunell S. Posture, position 

and surgical telescopes in dental 

hygiene. J Dent Educ 

1996;60(2):122. 

58. Rucker LM. Surgical magnification: 

Posture maker or posture breaker? 

Chapter 8 in: Murphy DC, editor. 

Ergonomics and the dental care 

worker. Washington, DC: American 

Public Health Association, 

1998:191-216. 

59. Valachi B, Valachi K. Mechanisms 

leading to musculoskeletal disorders 

in dentistry. J Am Dent Assoc 

2003;134(10):1344-1350. 

60. Valachi B, Valachi K. Preventing 

musculoskeletal disorders in clinical 

dentistry: Strategies to address the 

mechanisms leading to musculoskeletal 

disorders. J Am Dent 

Assoc 2003;134(12):1604-1612. 

61. Carr GB. Microscopic photography 

for the restorative dentist. J Esthet 

Restor Dent 2003;15(7):417-425. 

62. Behle C. Photography and the operating 

microscope in dentistry. J Calif 

Dent Assoc 2001;29(10):765-771. 

63. van As GA. Digital documentation 

and the dental operating microscope. 

Oral Health 

2001;91(12):19-20, 22-25. 

64. van As G. Erbium lasers in 

dentistry. Dent Clin North Am 

2004;48(4):1017-1059. 

65. Britto LR, Veazey WS, Manasse GR. 

Personal video monitor as an accessory 

to dental operating 

microscopes. Quintessence Int 

2004;35(2):151-154. ■■ 


129


130 

SCIENTIFIC REVIEW 

Detection of Caries by DIAGNOdent: 

Scientific Background and Performance 

Raimund Hibst, PhD, Institut für Lasertechnologien in der Medizin und Meßtechnik (ILM), 

Ulm, Germany 


SYNOPSIS 

Professor Hibst was one of the inventors of the DIAGNOdent laser 

fluorescence caries detection device. This article provides a review of 

the history, mechanism of action, and application of the device. 

INTRODUCTION 

The process of dental caries is 

accompanied by changes in the 

optical properties of the affected 

enamel or dentin. These changes in 

scattering, absorption, or fluorescence 

are the basis of visual/optical 

detection of carious lesions. First, 

demineralization of enamel results 

in an enlargement of intercrystalline 

spaces, which makes the tissue less 

homogeneous and results in an 

increase in light scattering (especially 

when the tooth is dried). As a 

result, decalcified enamel becomes 

visible as a highly scattering “white 

spot.” Later, the presence of chromophores 

in the lesion enhances 

light absorption so that the carious 

lesion appears brownish. 

A further tissue property which is 

affected by caries is fluorescence. 

Fluorescence is the re-emission of 

light by molecules after absorption. 

The fluorescence light always has a 

longer wavelength than the excitation 

light used for illumination. Its 

specific spectrum depends on the 

excitation wavelength and the molecular 

species. A variety of biological 

molecules shows fluorescence, especially 

proteins. Fluorescence of teeth 

on ultraviolet (UV) excitation was 

first described nearly one century 

ago. 1 When teeth were illuminated 

with invisible UV light from a Wood’s 

lamp, a bright fluorescence was 

observed by the naked eye. As early 

as 1927 it was noted that plaque 

shows different fluorescence properties 

when compared to sound tooth 

necks. 2 While all the early studies 

were performed with UV-excitation, 

the first experiments with visible 

light were reported beginning in 

1981. 3 In general, the investigations 

with UV, blue or green excitation 

light revealed a strong fluorescence 

of enamel, which is slightly altered 

when the tissue becomes carious. 

This phenomenon allows detection of 

demineralization in the outer surface 

regions (sometimes referred to as 

quantitative laser / light fluorescence, 

or QLF). However, strongly 

fluorescing healthy enamel optically 

masks changes in deeper layers, as 

scattering does, so that deeper 

lesions covered by intact tissue are 

difficult to detect by direct fluorescence 

changes. 

R ED EXCITED 

FLUORESCENCE 

The detection of hidden (occlusal) 

caries requires a low fluorescence 

from the overlying sound enamel, 

and a stronger emission from the 

lesion. Such a situation was found 

when excitation by red light was 

investigated. 4-6 Experiments showed 

that fluorescence yield decreased for 

longer excitation wavelengths, as 

expected, but this decrease was 

much more pronounced for sound 

surfaces than for carious lesions. 

With red light excitation (e.g., 655 

nm) carious lesions fluoresce much 

ABSTRACT 

Caries covered by macroscopically 

intact enamel can be detected by 

irradiating the teeth with red light 

and capturing the re-emitted 

infrared fluorescence radiation. 

This fluorescence originates from 

metabolites produced by caries 

bacteria. The optical caries 

detector DIAGNOdent ® measures 

this fluorescence and displays its 

intensity as a number. The instrument 

can detect hidden caries 

better than traditional methods 

and enables longitudinal monitoring 

of lesions. In order to avoid 

false positive diagnostic decisions, 

one should pay attention that 

calculus, stains, and some filling 

materials can also show fluorescence 

similar to caries lesions. 

more strongly. This is true across 

the entire emission wavelength 

range. Thus all fluorescence can be 

used for differentiation of healthy 

and diseased tissue. The possibility 

to utilize the total fluorescence light 

is an advantage of red excitation, 

which compensates in part for the 

lower intensities compared to excitation 

with shorter wavelengths. 

The considerable contrast between 

carious and sound enamel, or 

dentin, respectively, obtained for red 

excitation is demonstrated in Figure 

1, which shows a hemisectioned 

tooth and the corresponding fluorescence 

image. Both carious sites are 

clearly marked on the very low 

background fluorescence level. This 

offers a very elegant way to detect 

caries, because only the bright fluorescence 

spots in an otherwise dark 

environment are readily observed. 

This does not require 2-dimensional 

images and analysis. Additionally, 

Hibst

Figure 1: Hemisectioned tooth with approximal and occlusal caries 

Normal image with white light 

illumination 

the detection of hidden caries is 

possible, since the weaker sound 

enamel fluorescence does not 

completely mask the signal from a 

deeper lesion. Red light, and also 

infrared fluorescence radiation, is 

less absorbed and scattered by 

enamel than light of shorter wavelengths, 

so that in general red and 

infrared light penetrates deeper into 

the tooth. This also helps to increase 

the depth that can be examined. 

FLUOROPHORE 

I DENTIF ICATION 6 

In order to find the origin of fluorescence, 

one has to consider both 

the baseline fluorescence of sound 

dental tissue and its increase 

during the carious process. 

Sound enamel and dentin 

exhibit a low, but observable, fluorescence. 

The dominant component 

of enamel and dentin is the substituted 

hydroxyapatite (HA) calcium 

phosphate mineral. Experiments 

with pellets pressed out of 

powdered HA and various other 

calcium phosphates revealed very 

low signals. So it seems unlikely 

that calcium phosphates are 

responsible for the baseline fluorescence 

of sound teeth. By comparing 

teeth with different color one can 

Hibst 

Fluorescence image in false colors 

(655-nm excitation) 

observe that whiter teeth exhibit 

less fluorescence compared to 

darker ones. Presumably the same 

stains cause color and fluorescence. 

Demineralized enamel that was 

produced by chemical decalcification 

did not significantly enhance 

fluorescence. This corresponds to 

the finding of low calcium phosphate 

fluorescence described above. 

That is, simply removing mineral 

from these hard tissues does not 

significantly alter the fluorescence. 

Carious lesions show microscopically 

a strong correlation between 

brownish discoloration and fluorescence, 

so that brown chromophores 

might also act as fluorophores 

(substances that fluoresce). Besides 

natural carious lesions, calculus of 

various types also fluoresce under 

red light, including white calculus. 

So besides the brown pigments other 

fluorophores can be present. Likely 

candidates are bacteria or bacterial 

metabolites. To test this hypothesis, 

bacteria from carious lesions were 

incubated on blood agar and 

analyzed by fluorescence microscopy. 6 

Both the bacterial colonies and the 

surrounding agar showed fluorescence. 

Agar fluorescence decreased 

with increasing distance from the 

colonies, indicating that there are 


diffusible bacterial metabolites fluorescing 

under red light excitation 

(Figure 2). Candidates for bacterial 

metabolites that fluoresce could be 

the so-called porphyrins. Porphyrins 

occur as intermediate steps in the 

synthesis of heme, and are also 

produced by several types of oral 

bacteria, such as Prevotella intermedia 

or Porphyromonas gingivalis. 

In earlier work, porphyrins, especially 

Protoporphyrine IX (PPIX), 

indeed could be extracted from 

carious lesions and were demonstrated 

to be useful in differentiating 

caries from sound tooth structure by 

violet (406 nm) excited fluorescence. 7 

Although fluorescence yield is 

maximal for this short wavelength 

excitation, porphyrins were known to 

also show some fluorescence when 

excited by red light. Solutions of 

these molecules also fluoresce with 

655-nm excitation, and their emission 

spectra are very similar to those 

found for caries. 

Other substances occurring naturally 

in the mouth, like water, saliva, 

blood, or soft tissue do not exhibit 

fluorescence with red light excitation 

and thus do not interfere with caries 

detection. In contrast, chlorophyll 

does fluoresce, so that stains originating 

from food (leaves, wine, etc.) 

must also be considered as an origin 

of fluorescence (see below). 

DETECTOR SY S TEM 

AND APPLICATION 

On the basis of the investigations 

described above the optical caries 

detector DIAGNOdent ® (DD) was 

developed as a joint project 

between the Institut für 

Lasertechnologien in der Medizin 

und Meßtechnik (ILM, Ulm, 

Germany) and Kaltenbach and 

Voigt (KaVo, Biberach, Germany). 

The set-up and function are as 

follows. Light from a laser diode 

(655 nm) is coupled into an optical 

fiber and transmitted to the tooth. 

The excitation fiber is surrounded 

by a bundle of fibers which gather 

fluorescence as well as backscattered 

light and guide it to the 


131


132 


Figure 2: Fluorescence microscopic study of caries-related bacteria 

Figure 2a Figure 2b 

detection unit (Figure 3). By the use 

of a band pass filter in front of the 

photo diode detector, the backscattered 

excitation and short 

wavelength ambient light is 

absorbed. To discriminate the fluorescence 

from the ambient light in 

the same spectral region, the laser 

diode is modulated (i.e., the laser 

diode intensity is varied with a 

certain frequency). Due to its relatively 

short lifetime, fluorescence 

follows this modulation. By amplifying 

only the modulated portion of 

the signal, the ambient light is 

suppressed. The remaining signal is 

proportional to the detected fluorescence 

intensity and displayed as a 

number (0 to 99, in arbitrary units). 

In order to compensate for potential 

variations of the system (e.g., laser 

diode output power), the device can 

be calibrated by a ceramic standard 

of known and stable fluorescence 

yield. This makes the measurement 

absolute (although in arbitrary 

units) and allows comparisons of 

fluorescing tooth spots over time. 

Tests on solutions of varying PPIX 

concentrations demonstrated a 

linear response of the system (when 

the fluorophore concentration is 

increased by a factor of x, the signal 

increases by the same factor). 

Sensitivity was tested by applying 

small droplets of PPIX solution onto 

the enamel or dentin area of a 

hemisectioned tooth. On average 1 

picomole of PPIX results in a signal 

increase of 4 DD units. This 

compares to the baseline levels of 

sound teeth, and would be the 

detectable amount of porphyrins in 

superficial carious lesions. 6 

Figure 3: Schematic of the optical set-up 

of the DIAGNOdent caries detector device 

Figure 2c 

Figure 2a: Light microscopy of two 

different bacterial colonies on agar 

Figure 2b: Corresponding fluorescence 

image. Note the fluorescence also from 

the agar surrounding the colonies 

Figure 2c: Relative fluorescence intensity 

along the line marked on the image in 

Figure 2b 

In practical use the DD should be 

calibrated regularly (maybe daily) to 

assure comparable readings over 

time. After the tooth is cleaned, a 

sound spot on the smooth surface is 

measured in order to provide a 

baseline value. This value is then 

subtracted electronically from the 

fluorescence of the site to be measured. 

In order to measure and 

capture the signal from the entire 

carious lesion, the instrument has 

to be tilted around the measuring 

site. This ensures that the tip picks 

up fluorescence from the slopes of 

the fissure walls where the caries 

process often begins. A rising 

audible tone helps the examiner to 

find the maximum fluorescence 

value of the site under study. 9 

P ERFORMANCE 

A literature search (with Scopus; 

“DIAGNOdent” in title, keywords, 

or abstract) yields about 110 

published articles on the DD. A 

Hibst

large portion of these address questions 

concerning its: 

• reproducibility, reliability (probability 

that two measurements by 

the same (intraexaminer) or 

different (interexaminer) 

observers lead to the same result 

• sensitivity (ratio: true positive / 

(true positive + false negative), 

i.e., probability to correctly identify 

carious lesions) 

• specificity (ratio: true negative / 

(true negative + false positive), 

i.e., probability to correctly identify 

sound teeth). 

A systematic review on the DD 

performance 8 reveals persistent 

high intraexaminer and slightly 

lower but still good interexaminer 

reliability. The results on sensitivity 

and specificity are variable 

among the studies; the data range 

for the majority is given in Table 1. 

Sensitivity and specificity depend 

on the cut-off values used as the 

threshold to discriminate carious 

from sound tissue. As the threshold 

is lowered, more lesions are detected 

at the price of an increasing number 

of false positives. The few reported 

in vivo studies yielded a better 

performance than the majority of in 

vitro investigations. This might be 

due to changes in optical properties 

after extraction of the teeth 

(increase of scattering, loss of fluorescence). 

In the in vivo studies, a 

threshold of 20 DD units was chosen 

(in one study, 30). This can serve as 

guidance for the user’s (individually 

variable) threshold value. 

C ONCLUSION 

In conclusion, “the DD is clearly 

more sensitive than traditional diagnostic 

methods.” 8 However, the 

increased likelihood of false positive 

readings compared with that of 

visual methods gives rise to some 

concern. The specificity found in the 

studies would mathematically 

predict numerous unnecessary treatments 

for a collective of patients 

with low caries prevalence. However: 

• First, the studies were performed 

on samples with very high caries 

Hibst 

Table 1: Data Ranges for DIAGNOdent Performance * 

Condition Sensitivity Specificity 

prevalence (typically 20 to 50%) 

with numerous suspicious areas. 

Specificity with respect to these 

samples cannot be extrapolated to 

the general situation, since the 

DD will never show an increased 

signal for completely intact white 

teeth. The reason for false positive 

readings is always fluorescence, 

originating from stains (see 

above), calculus, or filing material. 

• Secondly, the DD is a detector 

and not a “diagnostic robot.” Its 

readings should be interpreted in 

the context of the situation. For 

example, if fissures of a tooth 

exhibit increased fluorescence 

but the surrounding area does 

not, it is more likely that it originates 

from superficial stain than 

from deeper caries. Even in the 

presence of fluorescing composites, 

information can be gained: 

An increase of fluorescence from 

the center to the periphery would 

indicate additional fluorophores 

(= caries) at the margin. 

In contrast to visual inspection 

(and also radiography), the DD 

provides quantitative data. These are 

not directly reflecting to “classical” 

lesion parameters like mineral loss 

or depth extension, but are related to 

the amount of fluorescing 

porphyrins. Since bacterial 

porphyrins accumulate in demineralized 

areas of increased depth and 

porosity, more severe lesions typically 

have higher concentrations of 

porphyrins. Therefore DD readings 

may provide quantitative data that 

can be related to the severity of tooth 

decay. DD readings are highly reproducible 

and this allows longitudinal 


Results 

Obtained in: 

enamel caries in vitro 0.72 - 0.95 0.68 - 0.95 9 of 13 studies 

dentinal caries in vitro 0.73 - 1.0 0.65 - 1.0 14 of 16 studies 

dentinal caries in vivo 0.92 - 0.96 0.63 - 0.86 3 of 4 studies 

*Based on data collected by Bader and Shugars from the majority of published studies on occlusal 

lesions. Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence 

device for detecting caries. J Am Dent Assoc 2004;135(10):1413-1426. 

monitoring of lesions. In all questionable 

situations with moderate 

fluorescence signals, it is reasonable 

to follow up the suspicious site at 

periodic examinations. Increasing 

fluorescence signals would indicate a 

progression of the lesion and thus 

indicate enhanced preventive or 

operative treatment. However, it is 

important to remember that the 

increase in fluorescence is a result of 

more absorption of external fluorophores 

into the more porous tooth 

structure, rather than directly 

detecting lesion size or extent. 

Recently, a miniaturized version 

of the DD was released 

(DIAGNOdent ® pen). First comparisons 

show that the new device 

performs on occlusal surfaces as well 

as the “classic” DIAGNOdent. 10 


Raimund Hibst has been educated in 

physics and biology. He received a 

PhD degree in physics from the 

University of Bochum, the venia 

legendi in biomedical engineering 

from the University of Ulm in 1995 

(medical faculty), and in 2000 he 

became professor for laser and 

dental technologies (Faculty of 

Engineering, University of Ulm). 

Since 1986 he has been with the 

Institut für Lasertechnologien in der 

Medizin und Meßtechnik, Ulm, 

Germany, where he is actually associate 

director and the head of the 

Dental Technology Center. His 

special interest is in optical methods 

in dentistry. Among his projects has 

been the development of an Er:YAG 

laser system for dental and oral therapeutic 

applications (KEY Laser ® ) 


133


134 


and caries detection by fluorescence, 

which is also now used in clinical 

practice (DIAGNOdent ® ). The 

Er:YAG laser research was awarded 

by the University of Ulm in 1990. In 

1998 he received the award for best 

cooperation with industry. Raimund 

Hibst is an editor of the journal 

Medical Laser Application and a 

board member of several journals. 

Dr. Hibst may be contacted by e-mail 

at raimund.hibst@ilm.uni-ulm.de. 

Disclosure: The caries detector 

DIAGNOdent has been developed in 

cooperation between ILM and KaVo. It 

is based on an invention made by the 

author and coworkers. For this, ILM 

receives royalties from KaVo which in 

part are passed down to the inventors. 

REFERENCES 

1. Stübel H. Die fluoreszenz tierischer 

gewebe in ultraviolettem licht. [The 

fluorescence of animal tissues by 

irradiation with ultraviolet light.] 

Pflugers Arch Gesamte Physiol 

Menschen Tiere 1911;142:1-14. 

2. Bommer S. Hautuntersuchungen im 

gefilterten Quarzlicht. 

[Investigations on skin with filtered 

quartz light.] Klin Wochenschr 

1927;6(24):1142-1144. 

3. Alfano RR, Yao SS. Human teeth 

with and without dental caries 

studied by visible luminescence 

spectroscopy. J Dent Res 

1981;60(2):120-122. 

4. Hibst R, Gall R. Development of a 

diode laser-based fluorescence caries 

detector. Caries Res 1998;32(4):294, 

abstract 80. 

5. Hibst R, Paulus, R. A new approach 

on fluorescence spectroscopy for 

caries detection. In: Featherstone 

JDB, Rechmann P, Fried D, editor. 

Lasers in dentistry V, January 24- 

25, 1999, San Jose, California. Proc 

SPIE 3593. SPIE – The 

International Society for Optical 

Engineering, Bellingham, 

Washington, 1999:141-147. 

6. Hibst R, Paulus R, Lussi A. 

Detection of occlusal caries by laser 

fluorescence: Basic and clinical 

investigations. Med Laser Appl 

2001;16(3):205-213. 

7. König K, Hibst R, Meyer H, 

Flemming G, Schneckenburger H. 

Laser-induced autofluorescence of 

carious regions of human teeth and 

caries-involved bacteria. In: Altshuler 

GB, Hibst R, editor. Dental applications 

of lasers, September 1-2, 1993, 

Budapest, Hungary. Proc SPIE 2080. 

SPIE – The International Society for 

Optical Engineering, Bellingham, 

Washington, 1993:170-180. 

8. Bader JD, Shugars DA. A systematic 

review of the performance of a 

laser fluorescence device for 

detecting caries. J Am Dent Assoc 

2004;135(10):1413-1426. 

9. Lussi A, Hibst R, Paulus R. 

DIAGNOdent: An optical method for 

caries detection. J Dent Res 

2004;83(Spec. Issue C):C80-C83. 

10. Lussi A, Hellwig E. Performance of 

a new laser fluorescence device for 

the detection of occlusal caries in 

vitro. J Dent 2006;34(7):467-471. 

For additional references, see the works 

cited within references 6, 8, and 9, 

above. ■■ 

Hibst

Reyhanian et al. 

CLINICAL REVIEW AND CASE REPORT 

Er:YAG Laser-Assisted Implant Periapical 

Lesion Therapy (IPL) and Guided Bone 

Regeneration (GBR) Technique: 

New Challenges and New Instrumentation 

Avi Reyhanian, DDS, Netanya, Israel; Donald J. Coluzzi, DDS, Redwood City, California 


SYNOPSIS 

The etiology and predisposing factors of implant periapical lesions 

are described and a case report of treatment using an Er:YAG laser is 

presented. 

INTRODUCTION 

Osseointegrated implants have been 

utilized as a successful treatment 

modality over three decades, with a 

high reported success rate, greater 

than 90 percent. 1-4 The predictability 

and high rate of success of dental 

implants makes them a standard 

treatment modality. Oftentimes in 

spite of exacting planning and 

precise placement accompanying the 

procedure, implant failure can and 

does still occur. 5-8 A small number of 

implants fail because of operator 

inexperience or clinically recognizable 

cause. Their widespread use in 

recent years has produced different 

types of complications which can be 

divided into two categories: 

1. Intraoperative Complications 

• Bleeding 

• Nerve injury 

• Mandibular fractures 

• Implant displacements 

• Accidental bone perforations 

• Incomplete flap closure 

2. Postoperative Complications 

• Mucositis and peri-implantitis 

• Implant periapical lesion (IPL) 

• Surgical wound dehiscence 

• Lesions on adjacent teeth 

• Incomplete osseointegration. 

Recent case reports introduced 

the term retrograde peri-implantitis 

as a lesion (radiolucency) 

around the most apical part of an 

osseointegrated implant. 9-11 It 

develops within the first month 

after insertion of the implant. 

The Etiology of Implant 

6, 9-10, 12-15 

Periapical Lesion 

1. Contamination of the implant 

surface 

10, 16-18 

2. Overheating of bone 

3. Overloading of the implant19 4. Presence of preexisting bone and 

12, 16, 20 

microbial pathology 

5. Presence of residual root fragments 

and foreign bodies in bone21 6. Implant placement in an infected 

maxillary sinus 

7. Implant placement in a poor 

bone quality site22-23 8. Lack of biocompatibility 

9. Excessive tightening of the 

implant and compression of the 

bone chips inside the apical hole, 

16, 24 

producing subsequent necrosis 

9, 16 

10. Contaminated implants. 

Predisposing Factors 25 

1. Patient characteristics: age, 

medical history 

ABSTRACT 

Osseointegrated implants have 

enjoyed a success rate of more 

than 90 percent. There are several 

reasons for failure including challenges 

during placement and 

postoperative complications. 

This article will discuss one of 

those failures, the implant periapical 

lesion (IPL) which is an 

accumulation of granulation tissue 

around the apical area of an 

implant. It is manifested as a radiographic 

radiolucency, and results 

in compromised osseous health 

and often requires the removal of 

the implant fixture. 

The etiology and predisposing 

factors of IPL will be enumerated, 

and descriptions of the classification, 

prevention, and treatment of 

IPL will be elaborated. 

A clinical case of IPL, treated 

with an erbium:YAG laser, will be 

presented. The detailed clinical 

protocol will be described. The 

seven-month postoperative clinical 

and radiographic findings show 

complete reversal of the lesion 

and change the prognosis from 

hopeless to good for the implant. 

2. Recipient site: local bone quality 

and quantity, cause of tooth loss 22, 

26-27 

3. Periodontal and endodontic 

7, 28 

conditions of neighboring teeth 

4. Implant characteristics: length, 

22, 29-32 

surface characteristics 

5. Surgical aspect: guided bone 

regeneration, osseous fenestration, 

or dehiscence. 10 


135


136 


Figure 1: An example radiograph of inactive 

implant periapical lesion around two 

implants 

Classification 

A classification of implant periapical 

lesions has been suggested that 

separate them into two categories: 

inactive and infected. 9 The inactive 

form is likely to appear as an apical 

scar, resulting from a residual bone 

cavity created by placing an implant 

that was shorter than the prepared 

drill site. An example is shown in 

Figure 1. The infected form occurs 

when an implant apex is placed in 

proximity to an existing infection or 

when a contaminated implant is 

placed (Figure 2). 

Prevention and Treatment 

Suggested preventions of implant 

periapical lesion include careful 

management of contaminants and 

heat generation during implant 

surgery. 

Treatment would vary according 

to the type of lesion. The inactive 

type is observed and monitored. 

The infected type requires surgical 

intervention, debridement of the 

infected lesion, systemic antibiotic, 

and/or guided bone regeneration. 

An implant apical resection or 

implant removal could be 

performed depending on the extent 

of the infection and the stability of 

6, 9, 12, 27, 33 

the implant. 

The Use of Er:YAG Laser in IPL 

Treatment 34-37 

• The erbium laser can make the 

initial flap incision, such as a 

crestal incision, or an intrasul- 

Figure 2: An example radiograph of an 

infected implant periapical lesion. The 

implant was later extracted 

cular or vertical releasing incision. 

The laser produces a wet 

incision (some bleeding) vs. a dry 

incision (no bleeding) such as that 

34, 36-38 

produced by the CO2 laser. 

• After the flap is raised, the 

erbium laser is also very efficient 

at vaporization of any granulation 

tissue, 34-35 with a lower risk 

of thermal damage to the bone 

than current diode or CO 2 

34, 39-40 

lasers. 

• The erbium laser provides detoxification 

of implant surfaces. 41 

Studies have demonstrated this 

laser’s bactericidal potential. 42-43 

• Furthermore, implant surface 

threads can be disinfected 

without damage by lasing 

directly on their surfaces with a 

low energy. 44-46 

• The erbium laser is also efficient 

at remodeling, shaping, and 

34, 36, 38, 47-48 

ablating necrotic bone. 

CASE OVERVIEW 

This case describes the use of an 

Er:YAG laser in treatment of periimplantitis 

of an implant periapical 

lesion and the advantages of this 

laser wavelength in performing a 

guided bone regeneration (GBR) 

technique versus conventional 

methods. 

Figure 3: Labial fistula on implant at 

tooth #7 

Examination 

A 56-year-old female presented 

with a noncontributory medical 

history. She was not taking any 

medications. She presented two 

months after she had 4 implants 

placed in the maxillary anterior 

area for teeth #7, 8, 9, and 10. The 

fixtures of #8 and 9 had failed the 

previous month and were removed; 

the implant for #10 was integrating 

normally, but #7 was 

compromised. 

Figure 4: X-ray image of the periapical 

lesion 

Reyhanian et al.

The patient had fair oral hygiene 

and brushed and flossed daily. 

Periodontal probing showed 3-mm 

pockets with no bleeding. The 

implant for tooth #7 was nonsubmerged 

and a labial fistula was 

present; furthermore, insertion of a 

probe into the fistula led to the end 

of the implant, and revealed loss of 

facial bone on the buccal side of the 

implant (Figure 3). The soft tissue 

around the failed implants in the 

area of #8 and 9 had healed well, 

the implant at the location of #10 

was submerged without soft tissue 

complications, and all other oral 

soft tissue appeared normal. 

Panoramic and periapical films 

showed a radiolucent area around 

the apical portion of the implant 

(Figure 4). The extent of buccal 

bone resorption could not be determined 

from the radiograph. 

The implant was stable with no 

mobility. 

Diagnosis 

The provisional and final diagnosis 

was peri-implantitis of the implant 

fixture for tooth #7 with an infected 

implant periapical lesion exhibiting 

severe bone loss on the buccal side 

of the implant. 

Treatment Plan 

Treatment would involve the use of 

an Er:YAG laser to perform: 

• the incision for a flap 

• ablation of granulation tissue 

around the implant 

• remodeling, shaping, and decortication 

of the bone 

• decontamination of exposed 

screw threads of the implant, and 

• a GBR procedure. 

Since the implant was not 

mobile, this technique has a good 

prognosis. 

Treatment alternatives could 

consist of traditional scalpel, 

curettes, citric acid, air flow, air 

abrasion 49 and rotary bone burs. 

Treatment 

An Er:YAG laser (OpusDuo 

AquaLite E , Lumenis Ltd., 


Figure 5: Er:YAG laser being used for incision. 

A 200-micron tip is used in contact 

mode at 9 W, 450 mJ / 20 Hz 

Figure 6: Flap being raised 

Figure 7: Er:YAG laser being used for granulation 

tissue ablation. A 1300-micron tip 

is used at 8.4 W, 700 mJ / 12 Hz 

Yokneam, Israel) with a wavelength 

of 2940 nm was used. 

An intrasulcular incision was 

made using a 200-micron sapphire 

tip in contact mode. The power 

setting was 9 W, 450 mJ / 20 Hz 

with a water spray. The incision 

extended posteriorly from the distal 

area of #8 to the distal of #6 

(Figure 5). Then a vertical 

releasing incision was made 

apically on #6, and a buccal flap 

was lifted (Figure 6). The infected 

area was then visualized. There 

was massive bone loss on the 


Figure 8: View immediately after ablation 

of granulation tissue and bone remodeling 

Figure 9: Bio-Oss ® placement completed 

Figure 10: Bio-Gide ® absorbent 

membrane in place 

buccal apical aspect of the implant 

with a great deal of granulation 

tissue. The lack of mobility of the 

implant was confirmed. 

The granulation tissue was 

ablated with the erbium laser in 

noncontact mode; the tip was a 

1300-micron sapphire tip at a 

power of 8.4 W, 700 mJ / 12 Hz 

with a water spray (Figure 7). The 

removal of this granulation tissue 

produced a crater around the end 

of the implant. Next, the laser 

parameters were reduced to 3 W, 


137


138 


Figure 11: Primary closure with sutures 

Figure 12: Ten-day postoperative view 

Figure 13: One-and-a-half-month postoperative 

view 

150 mJ / 20Hz and, with the same 

tip and water spray, the laser 

energy was aimed at the surface of 

the screw thread to obtain decontamination. 

Lastly, the laser was 

used to ablate the necrotic bone 

and to shape and remodel the site 

for GBR. A 1300-micron tip was 

used in noncontact with a power of 

9 W, 450 mJ / 20 Hz and water 

spray (Figure 8). After lasing, the 

defect was filled with Bio-Oss ® 

(Geistlich Pharma AG, Wolhusen, 

Switzerland), a bone substitute 

xenograft material, and covered 

Bio-Gide ® (Geistlich Pharma AG), 

an absorbent bilayer membrane 

Figure 14: One-and-a-half-month postoperative 

radiograph 

Figure 15: Seven-month postoperative 

view 

(Figures 9-10). The flap was 

sutured with 3-0 silk with careful 

attention paid to good primary 

closure (Figure 11). 

There are four important principles 

to keep in mind when 

performing GBR. 50-56 

• Fixation of the implant (the 

implant must be stable) 

• There must be complete and 

passive soft tissue coverage 

• There must be cortical stimulation 

by the material, and 

• The vertical releasing incision 

should be as far as possible from 

the GBR site to enable good 

primary closure. 

The purpose of GBR is to enable 

new bone formation, treat the 

anatomical defect, and improve the 

implant’s prognosis. The 

morphology of the defect is important 

for healing: the more walls of 

Figure 16: Seven-month postoperative 

radiograph 

bone left, the better the implant 

reacts. Deficiency of blood supply 

causes failure; to improve the blood 

supply to the bone graft, decortications 

of the bone are performed. 

Postoperative Instructions 

Clindamycin (150 mg x 50 tabs) 

was prescribed to prevent infection, 

and Motrin (800 mg x 15 tabs) for 

pain control. The patient was 

instructed to rinse with chlorhexidine 

0.2% starting the next day for 

2 weeks, three times a day, and was 

advised to maintain good oral 

hygiene. 

Management of Complications 

and Follow-Up Care 

The patient was examined the next 

day. She reported a moderate pain 

and moderate swelling of the cheek 

on the right side; but there was no 

tissue bleeding, the site was closed, 

and the flap was attaching with 

normal healing. Figure 12 depicts 

the 10-day postoperative view 

when the patient returned for 

inspection and suture removal. The 

swelling had resolved, there were 

no signs of fistula, and healing was 

progressing well. At six weeks, the 

soft tissue had healed over the 

bone and there were no bony 

projections (Figure 13), and the 

Reyhanian et al.

adiograph showed good integration 

(Figure 14). The seven-month 

intraoral view (Figure 15) and the 

radiograph (Figure 16) show full 

healing. The prognosis is very good. 

CONCLUSION 

The Er:YAG laser can be used for 

decontamination of infected 

implant surfaces and has been 

shown to be effective and safe. The 

use of this laser wavelength for 

those procedures presents advantages 

over conventional methods 

such as reducing the patient’s 

discomfort, and allowing better 

visualization in the surgical site. In 

addition, postoperative effects, such 

as pain and swelling, are less 

pronounced. This laser is an invaluable 

tool for those procedures by 

simplifying treatment and offering 

patients faster and less stressful 

oral therapy. 

AUTHOR BIOGRAPHIES 

Dr. Avi Reyhanian graduated from 

the University of Bucharest, 

Romania in 1988. He then participated 

in a fellowship program at 

the Oral and Maxillofacial 

Department, Rambam Hospital, in 

Haifa, Israel. He currently practices 

general dentistry and oral 

surgery in Netanya, Israel. Dr. 

Reyhanian first incorporated 

dental lasers in his practice in 

early 2002, and currently uses 

Er:YAG, CO 2 , and diode (830 nm) 

lasers. He has been performing 

periodontal surgery for the past 17 

years (the last four with lasers) 

and has completed more than 100 

cases of periodontal laser surgery. 

He is a member of the Academy of 

Laser Dentistry and the Israel 

Society of Dental Implantology. Dr. 

Reyhanian may be contacted by 

e-mail at: avi5000rey@gmail.com. 

Disclosure: Dr. Reyhanian has no 

commercial affiliations. 

Donald J. Coluzzi, DDS is a 1970 

graduate of the University of 

Southern California School of 


Dentistry. He recently retired after 35 

years from his general dental practice 

in Redwood City, California. He 

is an Associate Professor at the 

University of California San 

Francisco School of Dentistry 

Department of Preventive and 

Restorative Dental Sciences. He is 

past president of the Academy of 

Laser Dentistry and holds Advanced 

Proficiency certificates in Nd:YAG 

and Er:YAG laser wavelengths. He is 

a fellow of the American College of 

Dentists, and has received the Leon 

Goldman Award for Clinical 

Excellence and the Distinguished 

Service Award from the Academy of 

Laser Dentistry. He has published 

peer-reviewed manuscripts about 

lasers in dentistry, and along with 

Robert A. Convissar has co-authored 

the Atlas of Laser Applications in 

Dentistry, published by Quintessence 

Publishing Company in 2006. Dr. 

Coluzzi may be contacted by e-mail at 

don@laser-dentistry.com. 

Disclosure: Dr. Coluzzi is a lecturer 

for HOYA ConBio. He receives honoraria 

for those services. 

REFERENCES 

1. Adell R, Lekholm U, Rockler B, 

Brånemark PI. A 15-year study of 

osseointegrated implants in the 

treatment of the edentulous jaw. Int 

J Oral Surg 1981;10(6):387-416. 

2 Albrektsson T. A multicenter report 

on osseointegrated oral implants. J 

Prosthet Dent 1988;60(1):75-84. 

3. Buser D, Mericske-Stern R, Dula K, 

Lang NP. Clinical experience with 

one-stage, non-submerged dental 

implants. Adv Dent Res 

1999;13:153-161. 

4. Olsson M, Friberg B, Nilson H, 

Kultje C. MkII – A modified selftapping 

Brånemark implant: 3-year 

results of a controlled prospective 

pilot study. Int J Oral Maxillofac 

Implants 1995;10(1):15-21. 

5. Jaffin RA, Berman CL. The excessive 

loss of Branemark fixtures in 

type lV bone: A 5-year analysis. J 

Periodontol 1991;62(1):2-4. 

6. Esposito M, Hirsch J, Lekholm U, 


Thomsen P. Differential diagnosis 

and treatment strategies for biologic 

complications and failing oral 

implants: A review of the literature. 

Int J Oral Maxillofac Implants 

1999;14(4):473-490. 

7. Brisman DL, Brisman AS, Moses 

MS. Implant failures associated 

with asymptomatic endodontically 

treated teeth. J Am Dent Assoc 

2001;132(2):191-195. 

8. Ayangco L, Sheridan PJ. 

Development and treatment of 

retrograde peri-implantitis 

involving a site with history of 

failed endodontic and apicoectomy 

procedures: A series of reports. Int J 

Oral Maxillofac Implants 

2001;16(3):412-417. 

9. Reiser GM, Nevins M. The implant 

periapical lesion: Etiology, prevention, 

and treatment. Compend 

Contin Educ Dent 1995;16(8):768, 

770, 772, 774-777. 

10. Piattelli A, Scarano A, Piattelli M, 

Podda G. Implant periapical lesions: 

Clinical, histologic, and histochemical 

aspects. A case report. Int J 


1998;18(2):181-187. 

11. Yoon J, Oh T-J, Wang H-L. Implant 

periapical lesion: Potential etiology 

and treatment. J Korean Dent Assoc 

2002;40(5):388-397. 

12. McAllister BS, Master D, Meffer 

RM. Treatment of implants demonstrating 

periapical radiolucencies. 

Pract Periodontics Aesthet Dent 

1992;4(9):37-41. 

13. Scarano A, Di Domizio P, Petrone G, 

Iezzi G, Piattelli A. Implant periapical 

lesion: A clinical and 

histologic case report. J Oral 

Implantol 2000;26(2):109-113. 

14. Oh TJ, Yoon J, Wang HL. 

Management of the implant periapical 

lesion: A case report. Implant 

Dent 2003;12(1):41-46. 

15. Jalbout ZN, Tarnow DP. The implant 

periapical lesion: Four case reports 

and review of the literature. Pract 

Proced Aesthet Dent 2001;13(2):107- 

112, quiz 114. 

16. El Askary AS, Meffert RM, Griffin T. 

Why do dental implants fail? Part I. 

Implant Dent 1999;8(2):173-185. 

17. Eriksson A, Albrektsson T, Grane B, 


139


140 


McQueen D. Thermal injury to bone: 

A vital-microscopic description of 

heat effects. Int J Oral Surg 

1982;11(2):115-121. 

18. Yacker MJ, Klein M. The effect of 

irrigation on osteotomy depth and 

bur diameter. Int J Oral Maxillofac 

Implants 1996;11(5):634-638. 

19. Isidor F. Loss of osseointegration 

caused by occlusal load of oral 

implants. A clinical and radiographic 

study in monkeys. Clin 

Oral Implants Res 1996;7(2):143- 

152. 

20. Sussman HI, Moss SS. Localized 

osteomyelitis secondary to 

endodontic-implant pathosis. A case 

report. J Periodontol 1993;64(4):306- 

310. 

21. Park SH, Sorensen WP, Wang HL. 

Management and prevention of 

retrograde peri-implant infection 

from retained root tips: Two case 

reports. Int J Periodontics 

Restorative Dent 2004;24(5):422-433. 

22. Saadoun AP, Le Gall MG. An 8-year 

compilation of clinical results 

obtained with Steri-Oss endosseous 

implants. Compend Contin Educ 

Dent 1996;17(7):669-672, 674, 676, 

678, 680, 682-684, 686, 688, quiz 

688. 

23. Hutton J, Heath MR, Chai JY, 

Harnett J, Jemt T, Johns RB, 

McKenna S, McNamara DC, van 

Steenberghe D, Taylor R, Watson 

RM, Hermann T. Factors related to 

success and failure rates at 3-year 

follow-up in a multicenter study of 

overdentures supported by 

Brånemark implants. Int J Oral 

Maxillofac Implants 1995;10(1):33- 

42. 

24. Piattelli A, Scarano A, Balleri P, 

Favero GA. Clinical and histological 

evaluation of an active “implant 

periapical lesion”: A case report. Int 

J Oral Maxillofac Implants 

1998;13(5):713-716. 

25. Quirynen M, Vogels R, Alsaadi G, 

Naert I, Jacobs R, van Steenberghe 

D. Predisposing conditions for retrograde 

peri-implantitis, and 

treatment suggestions. Clin Oral 

Implants Res 2005;16(5):559-608. 

26. Albrektsson T, Dahl E, Enbom L, 

Engevall S, Engquist B, Eriksson 

AR, Feldmann G, Freiberg N, Glantz 

P-O, Kjellman O, Kristersson L, 

Kvint S, Köndell P-Å, Palmquist J, 

Werndahl L, Åstrand P. 

Osseointegrated oral implants. A 

Swedish multicenter study of 8139 

consecutively inserted Nobelpharma 

implants. J Periodontol 

1988;59(5):287-296. 

27. Sussman HI. Periapical implant 

pathology. J Oral Implantol 

1998;24(3):133-138. 

28. Shaffer M, Juruaz D, Haggerty PC. 

The effect of periradicular 

endodontic pathosis on the apical 

region of adjacent implants. Oral 

Surg Oral Med Oral Pathol Oral 

Radiol Endod 1998;86(5):578-581. 

29. Quirynen M, Naert I, van 

Steenberghe D, Dekeyser C, Callens 

A. Periodontal aspects of osseointegrated 

fixtures supporting a partial 

bridge. An up to 6-years retrospective 

study. J Clin Periodontol 

1992;19(2):118-126. 

30. Lekholm U, van Steenberghe D, 

Herrmann I, Bolender C, Folmer T, 

Gunne J, Henry P, Higuchi K, Laney 

WR, Linden U. Osseointegrated 

implants in the treatment of 

partially edentulous jaws: A 

prospective 5-year multicenter 

study. Int J Oral Maxillofac 

Implants 1994;9(6):627-635. 

31. Wheeler SL. Eight-year clinical 

retrospective study of titanium 

plasma-sprayed and hydroxyapatitecoated 

cylinder implants. Int J Oral 


350. 

32. Grunder U, Polizzi G, Goené R, 

Hatano N, Henry P, Jackson WJ, 

Kawamura K, Kohler S, Renouard F, 

Rosenberg R, Triplett G, Werbitt M, 

Lithner B. A 3-year prospective 

multicenter follow-up report on the 

immediate and delayed-immediate 

placement of implants. Int J Oral 


216. 

33. Balshi TJ, Pappas CE, Wolfinger GJ, 

Hernandez RE. Management of an 

abscess around the apex of a 

mandibular root form implant: 

Clinical report. Implant Dent 

1994;3(2):81-85. 

34. Sasaki KM, Aoki A, Ichinose S, 

Yoshino T, Yamada S, Ishikawa I. 

Scanning electron microscopy and 

Fourier transformed infrared spectroscopy 

analysis of bone removal 

using Er:YAG and CO2 lasers. J 

Periodontol 2002;73(6):643-652. 

35. Nelson JS, Orenstein A, Liaw LH, 

Berns MW. Mid-infrared 

erbium:YAG laser ablation of bone: 

The effect of laser osteotomy on 

bone healing. Lasers Surg Med 

1989;9(4):362-374. 

36. Ishikawa I, Aoki A, Takasaki AA. 

Potential applications of 

erbium:YAG laser in periodontics. J 

Periodontal Res 2004;39(4):275-285. 

37. Watanabe H, Ishikawa I, Suzuki M, 

Hasegawa K. Clinical assessments 

of the erbium:YAG laser for soft 

tissue surgery and scaling. J Clin 

Laser Med Surg 1996;14(2):67-75. 

38. Ishikawa I, Sasaki KM, Aoki A, 

Watanabe H. Effects of Er:YAG 

laser on periodontal therapy. J Int 

Acad Periodontol 2003;5(1):23-28. 

39. Schwarz F, Bieling K, Sculean A, 

Herten M, Becker J. Laser und 

ultraschall in der therapie periimplantärer 

infektionen – Eine 

literaturübersicht. [Treatment of 

periimplantitis with laser or ultrasound. 

A review of the literature.] 

Schweiz Monatsschr Zahnmed 

2004;114(12):1228-1235. 

40. Kreisler M, Al Haj H, d’Hoedt B. 

Temperature changes at the 

implant-bone interface during simulated 

surface decontamination with 

an Er:YAG laser. Int J Prosthodont 

2002;15(6):582-587. 

41. Schwarz F, Rothamel D, Becker J. 

Einfluss eines Er:YAG-lasers auf die 

oberflächen-struktur von titanimplantaten. 

[Influence of an 

Er:YAG laser on the surface structure 

of titanium implants.] Schweiz 

Monatsschr Zahnmed 

2003;113(6):660-671. 

42. Folwaczny M, Mehl A, Aggstaller H, 

Hickel R. Antimicrobial effects of 

2.94 microm Er:YAG laser radiation 

on root surfaces: An in vitro study. J 

Clin Periodontol 2002;29(1):73-78. 

43. Kreisler M, Kohnen W, Marinello C, 

Götz H, Duschner H, Jansen B, 

d’Hoedt B. Bactericidal effect of the 

Er:YAG laser on dental implant 

surfaces: An in vitro study. J 

Periodontol 2002;73(11):1292-1298. 

Reyhanian et al.

44. Matsuyama T, Aoki A, Oda S, 

Yoneyama T, Ishikawa I. Effect of 

the Er:YAG laser irradiation on titanium 

implant materials and 

contaminated implant abutment 

surfaces. J Clin Laser Med Surg 

2003;21(1):7-17. 

45. Schwarz F, Rothamel D, Sculean A, 

George T, Scherbaum W, Becker J. 

Effect of an Er:YAG laser and the 

Vector ultrasonic system on the 

biocompatibility of titanium 

implants in cultures of human 

osteoblast-like cells. Clin Oral 

Implants Res 2003;14(6):784-792. 

46. Kreisler M, Kohnen W, Christoffers 

AB, Götz H, Jansen B, Duschner H, 

d’Hoedt B. In vitro evaluation of the 

biocompatibility of contaminated 

implant surfaces treated with an 

Er:YAG laser and an air powder 

system. Clin Oral Implants Res 

2005;16(1):36-43. 

47. Aoki A, Yoshino T, Akiyama F, Miura 

M, Kinoshita A. Oda S, Watanabe H, 

Ishikawa I. Comparative study of 

Er:YAG laser and rotating bur for 

bone ablation. In: Ishikawa I, Frame 


JW, Aoki A, editors. Lasers in 

dentistry: Revolution of dental treatment 

in the new millennium. 

Proceedings of the 8th International 

Congress on Lasers in Dentistry, July 

31-August 2, 2002, Yokohama, Japan. 

Excerpta Medica International 

Congress Series 1248. Amsterdam: 

Elsevier Science B.V., 2003:389-391. 

48. Rupprecht S, Tangermann K, Kessler 

P, Neukam FW, Wiltfang J. Er:YAG 

laser osteotomy directed by sensor 

controlled systems. J Craniomaxillifac 

Surg 2003;31(6):337-342. 

49. Jovanovic SA. The management of 

peri-implant breakdown around 

functioning osseointegrated dental 

implants. J Periodontol 1993;64(11 

Suppl):1176-1183. 

50. Von Arx T, Kurt B, Hardt N. 

Treatment of severe peri-implant 

bone loss using autogenous bone and 

a resorbable membrane. Case report 

and literature review. Clin Oral 

Implants Res 1997;8(6):517-526. 

51. Meffert RM. How to treat ailing and 

failing implants. Implant Dent 

1992;1(1):25-33. 


52. Artzi Z, Tal H, Chweidan H. Bone 

regeneration for reintegration in 

peri-implant destruction. Compend 

Contin Educ Dent 1998;19(1):17-20, 

22-23, 26-28, quiz 30. 

53. Mellonig JT, Griffiths G, Mathys E, 

Spitznagel J. Treatment of the 

failing implant: Case reports. Int J 


1995;15(4):384-395. 

54. Lehmann B, Bragger U, Hammerle 

CH, Fourmousis I, Lang NP. 

Treatment of an early implant failure 

according to the principles of guided 

tissue regeneration (GTR). Clin Oral 

Implant Res 1992;3(1):42-48. 

55. Goldman MJ. Bone regeneration 

around a failing implant using guided 

tissue regeneration. A case report. J 

Periodontol 1992;63(5):473-476. 

56. Hammerle CH, Fourmousis I, Winkler 

JR, Weigel C, Brågger U, Lang NP. 

Successful bone fill in late periimplant 

defect using guided tissue 

regeneration. A short communication. 

J Periodontol 1995;66(4):303-308. ■■ 

The Dental Hygiene Laser Course 

Standard Proficiency Certification 

Laser Soft Tissue Management 

Patient Chairside Clinic 

Course Designed for Hygiene 

All Courses Held in Your Office with Your Laser • Technique Driven Instruction • Advanced Skills Training 

Academy of Laser Dentistry Recognized Course Provider 

Soft Tissue LASER Training 

Teri Gutierrez, RDH Certified Laser Educator 

Phone: 1-831-801-8210 or visit www.lasers4hygiene.com 

CALL TODAY FOR COURSE AVAILABILITY 


141


142 

CLINICAL CASE STUDIES 

Advanced Proficiency Case Studies 

Upcoming issues of the Journal will feature case 

studies from the most recent recipients of Advanced 

Proficiency. These clinicians completed the two-year 

process by successfully presenting one of these cases at 

the Academy of Laser Dentistry’s 2007 Annual 

Conference in Nashville, Tennessee. They are: Mary 

Lynn Smith, RDH; Charles Hoopingarner, DDS; and 

Steven Parker, BDS, LDS RCS, MFGDP. 

In this issue, Mrs. Smith utilizes an Nd:YAG laser 

as part of the protocol for initial treatment of periodontal 

disease. She explains how the laser is 

integrated into the therapeutic appointment and 

demonstrates the wavelength’s benefits in helping to 

control the disease. 

Dr. Hoopingarner performs gingival and osseous 

closed flap crown lengthening with an Er:YAG laser to 

help restore a bicuspid with a lingual cusp fracture 

that extended subgingivally. This case depicts the 

laser’s ability to ablate and contour both soft and hard 

tissue with precision and care, and ultimately to gain 

the necessary biologic width and tooth structure for a 

successful restoration. 

These cases show how different laser wavelengths 

can be routinely employed in a variety of dental procedures 

to produce safe, efficient, and excellent clinical 

results. ■■ 

Nd:YAG Laser Use in Treatment of Moderate 

Chronic Periodontitis 

Mary Lynn Smith, RDH 

McPherson, Kansas 

Treatment of a Subcrestal Tooth Fracture with 

the Er:YAG Laser 

Charles R. Hoopingarner, DDS 

Houston, Texas


144 

CLINICAL CASE 

Nd:YAG Laser Use in Treatment of 

Moderate Chronic Periodontitis 

Mary Lynn Smith, RDH, McPherson, Kansas 


SYNOPSIS 

This case report describes the use of an Nd:YAG laser as an integral 

component of the initial treatment of periodontal disease. 

PRETREATMENT 

A. Diagnostic Tests 

1. Full Clinical Description 

A healthy 47-year-old Hispanic male 

presented for examination. His chief 

complaint was the dark spot at the 

gingival margin of tooth #9 and 

limited chewing efficiency (Figure 1). 

His last dental visit was 6 months 

prior for an emergency extraction of 

tooth #19. He had never had any 

type of dental hygiene appointment. 

The patient speaks Spanish predominately, 

and communication was 

accomplished by the dentist translating 

information at specific times 

in each appointment. 

During the initial hygiene 

appointment, the health history was 

reviewed and tissues were visually 

screened for signs of oral cancer. 

Comprehensive restorative, periodontal, 

and radiographic exams 

were completed. Micro-ultrasonic 

scaling, biofilm removal, and coronal 

polishing were performed. The 

patient was educated concerning his 

oral health and probable progression 

of untreated disease. 

The patient was taking no 

medications and had no known allergies. 

He was missing nine teeth: #1, 

16, 17, 19, 20, 25, 26, 30, and 32. 

Decay was noted on teeth #3, 15, and 

18. Significant fractures were noted 

on tooth #18 as well. The occlusion 

was Angle’s classification I with 

normal TMJ function. Supragingival 

calculus and gingival inflammation 

indicated possible periodontal 

disease. Complete periodontal 

charting revealed periodontal 

probing depths of 2-7 mm. Areas of 

recession exposing 1 to 4 mm of root 

surface were 

present. 

Furcations and 

mobility were 

also noted on the 

molars. 

2. Radiographic 

Examination 

A full-mouth 

series with 4 

vertical bitewings 

and 14 

periapical films 

was taken to 

further evaluate 

bone loss and 

carious lesions 

(Figure 2). 

Decay was 

noted on teeth 

#3 and 18. 

Decay on #15 

was not detected 

radiographically. 

There was 

moderate gener- 

Figure 2: Full-mouth film series taken at 

initial visit Figure 3: Initial periodontal probing chart 

Figure 1: Preoperative full-smile photograph 

of patient at presentation 

alized horizontal bone loss with areas 

of severe vertical bone loss on posterior 

teeth. Areas of particular concern were 

teeth #2, 15, 18, and 31. These teeth 

were diagnosed as hopeless due to the 

periodontal involvement and/or decay 

present and were scheduled for extraction. 

Generalized moderate-to-heavy 

calculus was noted on the radiographs. 

Smith

3. Soft Tissue Status 

Tissues appeared inflamed and irritated 

with the presence of plaque 

and calculus. A complete six-point 

periodontal probing was performed 

with 7 mm as the greatest pocket 

depth. Generalized bleeding was 

evident and moderate-to-heavy 

subgingival calculus was present in 

posterior areas, as well as supragingivally 

on the lower anterior teeth. 

Gingival recession of 1-2 mm was 

noted on teeth #2, 3, 4, 5, 12, 13, 14, 

and 15 buccal surfaces and 1-4 mm 

on lingual surfaces of teeth #2, 3, 4, 

14, 15, 18, 23, 24, 27, 28, 29, 31. 

Mobility of class I was detected on 

tooth #14 and class II on #2, 15, 18, 

and 31. Class I furcations were 

found on #2, 3, 14, 15, 18, and 31, 

and class II furcations on #2, 15, 18, 

and 31 (Figure 3). A statistical 

summary of overall periodontal 

health showed 36 hemorrhaging 

sites upon probing, 45 periodontal 

pockets of 4 mm or greater, and 19 

teeth exhibiting beyond-normal 

limits in pocketing. (This summary 

excludes teeth #2, 15, 18, and 31 

which were diagnosed as hopeless.) 

The oral cancer screening was 

within normal limits. 

4. Hard Tissue Status 

• Missing teeth were #1, 16, 17, 19, 

20, 25, 26, 30, and 32 

• All other teeth were vital 

• Occlusion was Angle’s Class I 

• Decay was present on teeth #3 

DL, #15 O, and #18 DOL with 

fractures noted on the mesial, 

lingual and distal aspects 

• Limited mastication was present 

due to missing posterior teeth. 

5. Other Tests 

TMJ was normal. 

B. Diagnosis and Treatment Plan 

1. Diagnoses 

• Provisional diagnosis included 

chronic periodontitis with poor 

prognosis of molars. 

• The doctor’s final diagnosis was 

stated as severe generalized 

chronic periodontitis. Carious 

Smith 

lesions were present on teeth #3 

DL, #15 O, #18 DOL, with significant 

fractures on #18 MLD. 

2. Treatment Plan Outline 

a. Restorative treatment to include: 

• restoration of tooth #3 with a 

distolingual composite 

• simple extractions of teeth 

#2, 15, 18, and 31 

• replacement of teeth #19, 20, 

25, 26, and 30 with a partial 

denture or implants. 

b. Active phase-I periodontal infection 

therapy to include five 

periodontal infection therapy 

appointments, one hour each 

and scheduled approximately a 

week apart: 

• assessment of patient’s 

plaque management, refining 

techniques and continuing 

motivation for thorough daily 

care 

• micro-ultrasonic instrumentation 

and hand 

instrumentation for biofilm 

and calculus removal 

• laser soft tissue decontamination 

and superficial 

coagulation 

• intraoral photographs. 

c. Six-week post-therapy re-infection 

assessment appointment to 

include: 

• one appointment for 30 

minutes: 

• health history review 

• visual evaluation of tissue 

rehabilitation 

• assessment of patient’s plaque 

management, refining techniques 

and continuing motivation 

for thorough daily care 

• intraoral photographs 

• micro-ultrasonic biofilm 

removal at gingival third of 

tooth 

• probing and sulcular instrumentation 

is avoided in order 

to allow undisturbed maturation 

of connective tissue at 

the base of the pocket. 

d. Twelve-week post-therapy 

appointment to include: 


CLINICAL CASE 

• oral cancer screening 

• periodontal charting to 

assess rehabilitation 

• assessment of patient’s 


techniques and continuing 

motivation for thorough daily 

care 


for full-mouth 

bacterial decontamination 

and scaling as needed 

• coronal polishing 

• laser decontamination of 

unresolved areas 

• intraoral photos 

• determination of recare 

interval. 

3. Indications for Treatment 

Treatment is indicated to halt the 

periodontal destruction and rehabilitate 

the affected tissues. Periodontal 

infection therapy must include 

removal of biofilm and calculus from 

the root surfaces through scaling. The 

Nd:YAG laser furthers decontamination 

of the pocket by addressing the 

periodontal pocket wall. The 1,064nm 

laser wavelength is highly 

absorbed in melanin and hemoglobin. 

Both of these chromophores are 

present in inflammatory tissue. 

Laser-tissue interaction reduces 

pathogens in the pocket and coagulates 

hemorrhaging sites, assisting 

the body’s healing response. This 

laser enhances the body’s healing 

process by reducing bacterial counts 

and achieving superficial coagulation. 

4. Contraindications for Therapy 

and Precautions 

Though it could be beneficial to reduce 

pathogens prior to extraction, teeth 

diagnosed as hopeless were not 

considered for therapy. There were no 

contraindications for this patient to 

receive Nd:YAG laser-assisted treatment 

of periodontal disease. Laser 

safety precautions were followed for 

protection of the patient and clinician. 

The energy from the Nd:YAG 

laser must be directed toward the 

soft tissue and away from the tooth 

and bone. 


145


146 

CLINICAL CASE 

5. Treatment Alternatives 

Treatment alternatives included: 

• No treatment and progression of 

disease, eventual tooth loss and 

systemic impact 

• Conventional scaling and root 

planning 

• Placement of localized antimicrobials 

or antibiotics with possible 

reactions 

• Periodontal surgery. 

6. Informed Consent 

After being educated in the 

progression of untreated periodontal 

disease and treatment 

options, the patient gave verbal 

and written consent to proceed 

with the planned therapy. This is 

documented in the patient’s record. 

TREATMENT 

A. Restorative Treatment 

Objective 

Teeth #2, 15, 18, and 31 were 

extracted prior to phase I active 

periodontal infection therapy. 

Tooth #3 caries removal and 

composite restoration was placed 

after completion of therapy per the 

patient’s request. 

B. Periodontal Treatment 

Objective 

The treatment objectives are to 

halt the destruction of the periodontium 

due to disease processes. 

Laser-assisted periodontal treatment 

will reduce bacterial load in 

the periodontal pocket wall, eliminating 

the related inflammatory 

response by the body. The Nd:YAG 

laser wavelength is well absorbed 

in pigmented and hemoglobin-rich 

inflamed tissue. Signs of healing, 

such as decreased probing depths, 

elimination of hemorrhaging, and 

normal tissue coloration and 

texture, are desired. The appointments 

are designed to allow 

patient-customized education in 

specific daily plaque management 

techniques, ensuring maximum 

rehabilitation of the tissues. 

Beginning with the most infected 

teeth, each appointment will 

address three to four teeth for 

debridement of root surfaces 

through scaling, followed by tissue 

decontamination and superficial 

coagulation through lasing. At the 

subsequent appointment, approximately 

7 to 10 days later, a 

different group of teeth will be 

debrided and tissues lased. The 

previously treated area will be 

revisited for ultrasonic biofilm 

removal from tooth surfaces and 

laser decontamination of tissues. 

Instrumentation with the ultrasonic 

is concentrated on the 

cervical area of tooth structure and 

the fiber is calibrated to 1 mm less 

than the previous application. This 

continues the reduction of bacterial 

load and enhances the body’s 

healing response. It also allows 

reinforcement of behavior modification 

in daily plaque management. 

C. Laser Operating Parameters 

A free-running pulsed Nd:YAG 

laser (PulseMaster 600 IQ, 

American Dental Technologies, 

Corpus Christi, Texas) with a 1064nm 

emission wavelength was used 

with a 400-micron contact fiber. For 

bacterial reduction, the laser 

parameters were 30 mJ and 60 Hz, 

average power of 1.8 Watts for 

approximately 40 seconds per site; 

for superficial coagulation, the 

settings were 100 mJ and 20 Hz, 

with an average power of 2.0 Watts 

for approximately 20 seconds per 

site. The total laser emission time 

for the five sessions of periodontal 

infection therapy was 155 minutes. 

D. Treatment Delivery 

Sequence 

The treatment delivery sequence at 

each therapeutic appointment 

included: 

• review of health history 

• plaque management assessment 

and instruction 

• anesthetic as needed 

• topical anesthetic administered 

at the gingival margin and 

subgingivally. A compounded 

preparation called TAC (20% 

lidocaine, 4% tetracaine, and 2% 

phenylephrine) was used 

• local anesthetic of 2% lidocaine 

with epinephrine 1:100,000 was 

administered for more profound 

anesthesia 

• infiltration with 4% articaine 

with epinephrine 1:100,000 was 

administered when a full block 

was not necessary 

• micro-ultrasonic and hand 

instrument debridement of root 

surfaces 

• laser decontamination and superficial 

coagulation 

• postoperative care instructions 

given. 

Laser safety measures included: 

• use of 1,064-nm laser wavelength 

protective eyewear by all operatory 

personnel 

• use of 0.1-micron filtration masks 

• environment secured to limit 

access 

• laser-in-use warning sign placed 

• reflective surfaces minimized 

• high-volume evacuation utilized 

for plume control and to cool the 

tissue. 

Chart documentation included 

laser and wavelength used, fiber 

size and type, operating parameters, 

and emission time. 

The laser fiber was cleaved and 

the laser test-fired. The fiber was 

calibrated to 1 mm less than the 

pocket depth (Figure 4). With the 

fiber remaining in constant contact 

with the internal pocket tissue and 

in constant motion, treatment began 

at the top of the pocket and 

progressed apically, moving the fiber 

vertically and horizontally until the 

Figure 4: Laser fiber is calibrated to 1 

mm less than the pocket depth 

Smith

Figure 5: Any debris clinging to the fiber 

must be wiped off 

Figure 6: Intraoperative view showing the 

technique used on the upper right molar 

Figure 7: Intraoperative view demonstrating 

fresh bleeding which indicates 

that the laser use for this site is complete 

calibrated depth was reached. The 

fiber was always directed away from 

the root surface and toward the 

target tissue. Accumulated debris 

was wiped from the fiber and a 

proper cleave maintained (Figure 5). 

Figure 6 shows the laser technique 

on tooth #3, which is featured in 

this case. The amount of lasing time 

was influenced by tissue interaction, 

extent of disease, and depth of the 

pocket. When fresh bleeding was 

visible, the laser procedure was 

Smith 

Figure 8: Tooth #14 procedure Figure 9: Tooth #28 procedure 

Figure 8a: Initial mesiobuccal pocket on 

tooth #14 

Figure 8b: Laser treatment of pocket 

Figure 8c: Immediate postoperative view 

deemed complete for that site 

(Figure 7). High-volume suction was 

present to eliminate the plume and 

cool the tissue. 

Several figures demonstrate the 

typical treatment protocol in two 

different areas of the mouth. 

Figure 8a shows initial mesial 

pocket depth of tooth #14, 8b shows 

the laser treatment, and 8c shows 

the immediate postoperative coagulation. 

CLINICAL CASE 

Figure 9a: Initial mesiolingual pocket on 

tooth #28 

Figure 9b: Laser treatment of pocket 

Figure 9c: Immediate postoperative view 

Figure 9a shows the mesiolingual 

pocket of tooth #28, 9b 

shows the laser treatment, and 9c 

shows the immediate postoperative 

coagulation. 

E. Postoperative Instructions 

Postoperative instructions were 

given in verbal and written form. 

The patient was instructed to avoid 

(for the first 24 hours) acidic, rough, 

or crunchy foods. Normal eating 


147


148 

CLINICAL CASE 

could resume following that period. 

Avoidance of seeds, husks, and 

other foods that may lodge between 

the gingiva and tooth was recom- 

Figure 10: One-week postoperative views 

Figure 10a: One-week postoperative view 

of tooth #14 

Figure 10b: One-week postoperative view 

of tooth #28 

mended for a week. In the areas 

lased, subgingival flossing and the 

small Sulcabrush ® (Sulcabrush Inc., 

Niagara Falls, N.Y.) were to be 

avoided for several days. Use of an 

ultrasoft toothbrush and supragingival 

cleaning was recommended. 

All other areas were to be cleaned 

as usual. If discomfort were to 

occur, the patient was instructed to 

use warm salt water rinses and 

over-the-counter pain medication. 

The patient was informed that the 

most important aspect of the 

therapy was the healing process, 

and minimizing plaque at the 

gingival margin was critical in 

preventing re-infection. 

F. Complications 

The patient experienced cold sensitivity. 

He was prescribed 1.1% 

neutral sodium fluoride with potassium 

nitrate for daily use. It was 

effective and he had no other 

complications during or after the 

laser treatments. 

G. Prognosis 

Prognosis overall is good as long as 

the patient 

conforms to good 

oral hygiene and 

recommended 

intervals for 

professional 

supportive maintenance 

visits. 

Periodontally, 

teeth #3 and 14 

will be monitored 

for continued 

improvement. 

Restorative treatment 

is needed to 

reduce functional 

stresses on 

existing teeth. 

FOLLOW-UP CARE 

A. Assessment of Treatment 

Outcomes 

The patient was assessed at 1 

week, 6 weeks, 12 weeks, and 6 

months following active phase-I 

periodontal infection therapy. 

Periodontal charts show comparative 

data of initial state to 12 

weeks post-therapy as well as 6 

months post-therapy. Percentage of 

improvement is seen with 92% in 

bleeding reduction, 80% in pocket 

site reduction, and 68% fewer teeth 

exhibiting periodontal pocketing. 

The one-week examination 

revealed that the tissues were 

healing and the patient’s skill in 

plaque management was 

improving. For example, Figure 10a 

shows the one-week view of tooth 

#14, and Figure 10b shows the oneweek 

view of tooth #28. 

Figure 12: Twelve-week postoperative 

probing 

Figure 12a: Tooth #14 

Figure 11: Twelve-week postoperative periodontal probing chart 

H. Documentation 

All treatment and 

related information 

was recorded 

in the patient’s 

treatment record. Figure 12b: Tooth #28 

Smith

Six-week post-therapy reinfection 

assessment 

appointment included: 

• confirmation that the patient is 

maintaining plaque control. 

Smith 

Tissues are continuing to 

improve. 


• visual evaluation of tissue 

rehabilitation 

• assessment of the 

patient’s plaque 

management, 

refining techniques 

and 

continuing motivation 

for 

thorough daily 

care 

• intraoral photographs 

• micro-ultrasonic 

biofilm removal 

at gingival third 

of tooth 

• probing and 

sulcular instrumentation 

was 

avoided in order 

to allow undisturbed 

maturation of 

connective tissue 

at the base of the 

pocket. 

Twelve-week 

Figure 13: Six-month postoperative periodontal probing chart post-therapy 

appointment: 

Figure 14: Six-month postoperative probing Overall, a marked improvement was 

seen in periodontal health, such as 

decreased probing depths, decreased 

bleeding on probing, normal tissue 

coloration, firm texture, and lack of 

mobility. Teeth #3 and 14 need 

continued refinement of plaque 

management and further therapy. 

This appointment included: 



Figure 14a: Tooth #14 

• six-point pocket and hemorrhaging 

periodontal charting to 

assess rehabilitation (Figure 11) 

• assessment of the patient’s 


techniques and continuing motivation 

for thorough daily care 


for full-mouth bacterial decontamination 


Figure 14b: Tooth #28 

instrumentation as needed 

Figure 15: Comparison views 

CLINICAL CASE 

Figure 15a: Preoperative full smile at 

presentation 

Figure 15b: Six-month postoperative full 

smile 


• laser decontamination of appropriate 

areas 

• determination of recare interval 

at 12 weeks. 

The previously mentioned 

Nd:YAG laser was used with a 

setting for decontamination of 30 mJ 

and 60 Hz, 1.8 Watts average power, 

and additional hemostasis application 

for teeth #3 and 14 at 100 mJ 

and 20 Hz, 2.0 Watts delivered with 

a 400-micron contact fiber for 7 

minutes total emission time. Oral 

hygiene instructions were reviewed. 

Continued use of daily fluoride as 

caries prevention was recommended. 

A 12-week supportive periodontal 

therapy appointment was scheduled. 

Short-term follow-up for tooth #14 is 

shown in Figure 12a and for tooth 

#28 in Figure 12b. 

Six-month post-therapy 

appointment: 

Tissue health is maintaining very 

well. Tooth #3 is continuing to 

improve while #14 remains an area 

of concern. Periodontal chartings 

compare the initial, 12-week, and 


149


150 

CLINICAL CASE 

Table 1: Results of Laser-Assisted Therapy 

Treatment 

Assessment Interval 

Number of Sites 

with Bleeding 

on Probing 

6-month periodontal status. The 6month 

therapeutic appointment 

included: 



• six-point periodontal charting 

(Figure 13) 

• assessment of the patient’s 


techniques and continuing motivation 

for thorough daily care; 

instructions to continue daily 

fluoride applications 


for full-mouth bacterial decontamination 


instrumentation as needed 


• laser decontamination of appropriate 

areas 

• instruction to continue 12-week 

maintenance interval. 

The previously mentioned 

Nd:YAG laser was used with a 400micron 

fiber and parameters of 30 

Hz, 60 mJ, average power of 1.8 

Watts for decontamination. 

Hemostatic assistance was accomplished 

with 100 mJ, 20 Hz, 

average power of 2.0 Watts applied 

to sites of tooth #14 due to 

increased inflammation. Emission 

time totaled 8 minutes. Long-term 

follow-up is illustrated: Figure 14a 

shows the 6-month probing of tooth 

#14 and 14b shows tooth #28. 

Number of Sites 

with Periodontal 

Pockets 4 mm or 

Greater 

Number of Teeth 

with Beyond-Normal 

Periodontal 

Pocketing 

Beginning 36 45 19 of 19 

12 Weeks 3 9 6 of 19 

6 Months 7 4 2 of 19 

Rate of Improvement 

After 6 Months 

81% 91% 90% 

B. Complications 

Continued daily use of fluoride was 

recommended for caries prevention. 

The patient had no soft or hard 

tissue damage and was pleased 

with the results from the laser. 

C. Long-Term Results 

At 12 weeks post-therapy there 

was marked improvement. 

Hemorrhaging sites were reduced 

by 92%, number of perio sites by 

80%, and number of teeth affected 

by 68%. At 6 months post-therapy, 

the patient had an increase in 

hemorrhaging sites but other 

improvements continued. The 

patient’s health compared to his 

initial state showed improvements 

of 81% in hemorrhaging, 91% in 

perio sites, and 90% number of 

teeth affected (Table 1). Figures 

15a and 15b show the comparison 

of tissues initially and at 6 months 

post-therapy. 

D. Long-Term Prognosis 

The patient was compliant with all 

treatment aspects and a good prognosis 

exists. It will require 

conformity to good oral hygiene and 

continued professional supportive 

maintenance visits at 12-week 

intervals. Periodontally, teeth #3 

and 14 will be monitored for 

continued improvement. 

Adjustment of the maintenance 

interval and adjunctive use of 

Arestin ® (OraPharma Inc., 

Warminster, Pa.) are possible. In 

the case of acute and rapid progression, 

surgical intervention or 

extraction may be indicated. 

Replacement of missing 

mandibular teeth will be very 

important to alleviate excessive 

functional stress on existing teeth. 

If a partial denture is chosen 

rather than implants, caries 

prevention and periodontal 

stability of supporting teeth will be 

a concern. Caries prevention 

strategy includes effective daily 

plaque management, daily use of 

fluoride, and reduced acid sources 

in diet, as well as consistent professional 

care. An oral irrigator for 

daily use would be beneficial for all 

teeth present. 


Mary Lynn Smith is a registered 

dental hygienist, working clinically 

for more than 12 years. She 

achieved her Standard Proficiency 

in the Nd:YAG (1,064-nm) and 

diode (810-nm) wavelengths in 

2003, and completed her 

Advanced Proficiency in the 

Nd:YAG in 2007. Mary Lynn has 

contributed to the dental community 

through articles and 

speaking to fellow hygienists on 

care of implants, periodontal therapies, 

and laser-assisted hygiene 

techniques and principles. She 

currently resides in McPherson, 

Kansas and is employed by Dr. 

Jon Julian, DDS. Mrs. Smith may 

be contacted by 

e-mail at mlsrdh@swbell.net. 

Disclosure: Mrs. Smith has no 

commercial relationships relative to 

this case presentation. ■■ 

Smith

Treatment of a Subcrestal Tooth 

Fracture with the Er:YAG Laser 

Charles R. Hoopingarner, DDS, Houston, Texas 


SYNOPSIS 

This article describes gingival and osseous closed flap crown length- 

ening with an Er:YAG laser to help restore a bicuspid with a lingual 

cusp fracture that extends subgingivally. 

PRETREATMENT 

A. Outline of Case 

1. Full Clinical Description 

A 62-year-old Caucasian male 

presented with severe pain on 

chewing in the area of tooth #13. 

Figure 1 shows a deep vertical fracture 

of an existing MOD ceramic 

onlay and the underlying palatal 

cusp. He had complained of occasional 

biting sensitivity at two 

previous recare visits. No definitive 

findings were made at either visit. At 

that time a vital pulp test and radiographic 

evaluation were performed, 

and a minor occlusal adjustment was 

made. He had been an 11-year 

patient in the practice and maintained 

a very good level of dental 

health, and it was expected he would 

continue to be followed in our office. 

A recare evaluation and prophylaxis 

had been performed 3 months prior 

to the onset of the obvious fracture 

and extreme pain with no other 

pathologic dental or significant periodontal 

findings. He is allergic to 

Hoopingarner 

penicillin and on presentation his 

vital signs were within normal limits 

(blood pressure 115/68, pulse 64). He 

was taking no medications and had 

no further contributing medical 

history. He has a well-restored Class 

I dental occlusion and has cast 

restorations on teeth #4, 15, 29, and 

30. He had existing intracoronal 

restorations in teeth #2, 3, 6, 12, 14, 

18, 19, 20, 28, and 31. 

2. Radiographic Examination 

Previous panoramic X-ray showed 

no significant bone loss or any 

lesions present. A periapical X-ray 

did not show apical pathology or 

vertical bone loss present (Figure 2). 

3. Soft Tissue Status 

An oral cancer screen and periodontal 

probing had been 

CLINICAL CASE 

Figure 1: Preoperative view of fractured 

lingual cusp at presentation 

performed within a three-month 

period. When done, no soft tissue 

lesions were present, and no pocket 

depth measurements were in 

excess of 4 mm, as shown in Figure 

3. (As is the custom in our office, no 

pocket depths less than 4 mm were 

recorded.) 

Tooth #13 was probed and there 

were no readings in excess of 3 mm 

except along the border of the fractured 

segment. There was 

periodontal attachment present on 

the fractured segment and a 4-5 

mm measurement from the gingival 

crest to the remaining attachment. 

Figure 2: Periapical radiograph taken at 

presentation Figure 3: Periodontal probe chart. Pockets less than 4 mm are not charted 


151


152 

CLINICAL CASE 

4. Hard Tissue Status 

All bone levels and ridge topography 

had historically been within 

acceptable limits. The area around 

tooth #13 showed no vertical bone 

loss. The palatal cusp of tooth #13 

had fractured below the attachment 

level and after removal would 

show a termination at the osseous 

crest. There were signs of bruxism 

present and the patient reported 

that he was wearing a nighttime 

protective appliance that had been 

prescribed many years prior to this 

presentation. The tooth tested vital 

to air spray stimulation and it was 

necessary to use injected local 

anesthesia to fully evaluate the 

extent of the fracture. 

5. Other Tests 

TMJ evaluation showed normal 

range of motion and no joint 

sounds were present. 

B. Diagnosis and Treatment 

Plan 

1. Provisional Diagnosis 

A provisional diagnosis of vertical 

fracture of the palatal cusp of tooth 

#13 was made. It was thought that 

the fracture would extend to the 

osseous crest in a limited area, 

making impression-taking difficult. 

The position of the osseous crest 

obviated a consideration of biologic 

width issues. There was no pulpal 

exposure evident. 

2. Final Diagnosis 

A final diagnosis of vertical fracture 

of the palatal cusp of tooth #13 

was made. Figure 4 shows the fragment 

being removed. The extent of 

the fracture was limited to areas 

coronal to the periodontal attachment 

except for an approximate 

3-mm linear area in a readily 

accessible area of the palatal 

osseous crest, as seen in Figure 5. 

Since the fracture was observed to 

terminate at the osseous crest, any 

restoration would impinge on the 

biologic width necessary to maintain 

a healthy tooth support 

system. 

Figure 4: Removal of fractured segment 

3. Treatment Plan Outline 

The objective was to restore the 

patient’s tooth with a bonded 

ceramic restoration that would 

restore nearly ideal tooth form and 

permit proper attachment levels 

without invasion of the biologic 

width necessary to maintain periodontal 

health. Initially the tooth 

would be prepared to allow for 

coverage of the fractured areas. The 

preparation would be as conservative 

as possible as utilization of a 

bonded restoration did not require 

apical preparation extension for the 

purpose of retention. This procedure 

would be done with 

conventional rotary instruments. If 

the fractured root structure could 

be smoothed to allow placement of 

a margin at a more coronal level, 

that would become a part of the 

procedure. 

The 2940-nm Er:YAG laser 

would be used for two procedures. 

The first would be to contour the 

soft tissue in a manner that would 

leave the margins of the restoration 

at the gingival crest. The 

second procedure would be to 

remove osseous tissue to a level 3 

mm below the intended margin and 

bevel the bone to a normal contour. 

4. Indications 

As the 2940-nm Er:YAG laser 

wavelength is highly absorbed by 

both water and hydroxyapatite, it 

can be used to both contour the soft 

tissue and lower the bone level 

where indicated to establish a 

healthy attachment. With a closed 

Figure 5: Preoperative view of existing 

sound tooth structure, showing that the 

extent of the fracture is subgingival 

flap technique, the postoperative 

recovery is shortened and the 

patient discomfort level is minimized. 

With this approach 

impressions could be taken at the 

time of surgery and the restoration 

placed within the time frame of a 

normal delivery. 

5. Contraindications 

There were no contraindications for 

performing this procedure. 

6. Precautions 

During the initial gingival recontour 

it is necessary to carefully 

consider the desired outcome after 

healing. The soft tissue ablation 

should be performed by angling the 

tip in a manner to avoid damaging 

tooth structure. As the final 

contours are approached, care must 

be taken to avoid interacting with 

the bone prior to the initiation of 

water spray. Rehearsal of the bone 

ablating stroke is often necessary 

as the water spray can impair 

direct visualization. 

7. Treatment Alternatives 

Conventional flap surgery with 

gingival sculpting using scalpel 

technique and bone recontouring 

with rotary instruments or chisels 

is an alternative. Tooth extraction 

is an alternative. 

8. Informed Consent 

After a description of advantages, 

possible complications, and treatment 

alternatives were discussed, 

and all the patient’s questions were 

Hoopingarner

Figure 6: The Er:YAG laser is used first to 

contour and establish the height of the 

gingival marginal tissue 

answered, the patient’s verbal and 

written informed consent was 

obtained. 

TREATMENT 

A. Treatment Objectives 

The objective is to remove the fractured 

fragment, prepare the tooth, 

smooth the root surface, contour 

the gingiva, take an accurate 

impression, recontour the osseous 

crest to allow for proper biologic 

width formation, and place a wellformed 

provisional restoration so 

that bonded cementation could 

occur in a timely fashion. The 

Er:YAG laser will be used for 

recontouring both the gingival 

tissues and the osseous tissue. 

B. Laser Operating Parameters 

Laser: Er:YAG (DELight, HOYA 

ConBio, Fremont, Calif.): 

• Delivery system: Fiber-optic 

system consisting of varying 

quartz tips: 600-micron for initial 

tissue ablation, 400-micron for 

osseous recontouring, and 1200 x 

300-micron chisel tip for tissue 

and osseous beveling and 

smoothing 

• Wavelength: 2940 nm 

• Mode: Free-running pulsed 

• Pulse width: 300 microseconds 

• Power: 1.5 Watts (30 Hz and 50 

mJ) 

• Beam Diameter: Varied, 400 to 

600 microns using focused and 

defocused patterns 

• Repetition rate: 30 Hz 

• Continuous air (reduced volume 

and water spray for osseous 

Hoopingarner 

Figure 7: A probe is used to determine 

that the osseous crest is less than 1 mm 

apical to the gingival margin 

procedures, and air only for soft 

tissue) 

Laser settings: 

• Soft tissue ablation: 30 Hz and 

50 mJ, air cooling and no water 

• Osseous recontouring: 30 Hz and 

50 mJ with air and water spray 

Tips were used in both light 

contact and defocused modes. 

C. Treatment Delivery 

Sequence 

Pretreatment: The operatory was 

secured and the laser warning sign 

was posted. The laser unit was 

properly placed and connected to 

an air supply. Safety glasses with 

4+ optical density for the 2940-nm 

laser wavelength that met ANSI 

standards Z136.1 and Z136.3 were 

used. All shiny reflective objects 

were removed. The operatory was 

set up and supplied according to 

the standard for a restorative and a 

surgical procedure. Charting and 

radiographs were visible to the 

operator. The procedure was 

reviewed with staff in the morning 

report meeting. Prior to administration 

of anesthesia, the treatment 

was reviewed with the patient and 

informed consent was confirmed. 

The patient was properly draped 

and approximately 1.5 cc prilocaine 

4% 1:200,000 epinephrine was 

distributed by infiltration in the 

maxillary premolar segment. 

Approximately 0.4 cc prilocaine 4% 

1:200,000 epinephrine was injected 

6 mm below the palatal gingival 

crest of tooth #13. Eye protection 

was placed on the patient as well 

CLINICAL CASE 

Figure 8: Osseous tissue is removed and 

contoured with the laser, with the tip 

sleeve being used as a depth guide 

as the operator and assistant. The 

laser was test-fired in a safe direction 

after eye protection was placed 

and prior to the first soft tissue 

procedure. The first laser procedure 

was to recontour the soft tissue to 

approximate the intended margin 

of the preparation. This was done 

with near but noncontact strokes 

with a 600-micron tip and energy 

settings of 30 Hz and 50 mJ 

(Figure 6). The tissue was beveled 

as necessary to produce a physiologic 

crestal roll. This entailed an 

exposure time of less than 3 

minutes. No water was used for 

this part of the procedure and the 

tip was carefully aligned to avoid 

scarring the tooth. 

The distance from the fracture 

margin to the osseous crest was 

determined to be less than 1 mm. 

The probing of this depth is shown 

in Figure 7. It was felt that a 

margin could be placed 1 mm 

coronal to the extent of the fracture 

if the root were shaped and 

polished using rotary instruments 

and curettes. After this procedure 

was accomplished, there was still a 

distance of only 2 mm from the 

intended margin to the osseous 

crest. With copious water spray, a 

400-micron tip, and the same 

energy settings (30 Hz and 50 mJ), 

the bone was ablated to allow for a 

distance of slightly more than 3 

mm from the osseous crest to the 

intended preparation margin. This 

was done with short, noncontact 

strokes, with care being taken to 

avoid scarring the tooth. The 3-mm 


153


154 

CLINICAL CASE 

Figure 9: Initial tooth preparation 

showing contouring of fractured area 

Figure 10: A probe is used to confirm 

adequate biologic width 

sleeve on the 400-micron tip was 

used as a guide, as shown in Figure 

8. Had this convenient marking 

apparatus not been available, ink 

or stopper material could have 

been used as a measuring guide. 

With the 600-micron tip and the 

chisel tip, the bone was beveled to 

approximate a normal crestal 

contour. Total exposure time for the 

osseous segment was less than 7 

minutes. This gave a total exposure 

time of less than 10 minutes. 

With the depth of the fracture 

area left untouched where the root 

was smoothed, the tooth was 

prepared in a conservative manner 

to receive a ceramic restoration 

(Empress ® , Ivoclar Vivadent Inc., 

Amherst, N.Y.), as shown in Figure 

9. Figure 10 shows the confirmation 

of the new osseous level to be just 

over 3 mm from the intended preparation 

margin. A deep chamfer/ 

shoulder margin was then placed in 

that area, with care being taken to 

maintain the desired crest-to-margin 

distance, and the preparation was 

completed (Figure 11). 

With care taken to operate in a 

Figure 11: Final tooth preparation 

completed 

Figure 12: Impression clearly shows 

lingual margin of preparation 

noncontact mode, gingival hemorrhage 

was greatly reduced. The final 

impression was obtained during the 

operative visit. The crisp, clear 

impression again confirmed the 

osseous crest depth (Figure 12). 

A provisional restoration of 

temporary crown and bridge material 

(Integrity TM , Dentsply, York, 

Pa.), shown in Figure 13, was 

placed to maintain tissue contour. 

The provisional was evaluated at 

48 hours and no signs of infection 

or significant inflammation were 

present. 

Due to patient travel requirements 

it was necessary to bond the 

final restoration just 10 days after 

preparation. There was minimal 

soft tissue invasion in the deep 

marginal area (Figure 14) which 

was easily removed with a 3% 

hydrogen peroxide scrub. The 

restoration was bonded with a total 

etch protocol using a single-component 

adhesive (Optibond ® Solo 

Plus , Kerr Corporation, Orange, 

Calif.) as a bonding agent and an 

adhesive resin (Nexus II, Kerr 

Corporation) as a cement. This was 

Figure 13: Provisional restoration in place 

Figure 14: Ten-day postoperative view of 

preparation and tissue prior to bonding 

of restoration 

Figure 15: Immediate post-bonding 

lingual view 

performed in light-cure-only mode, 

and cured for 10 seconds at all four 

interproximal corners and 20 

seconds on the buccal, occlusal, and 

palatal surfaces (Figure 15). 

D. Postoperative Instructions 

The patient was told to avoid foods 

warmer than room temperature for 

48 hours and then begin hot saline 

mouth rinses. The area was to be 

cleaned with hydrogen peroxide on 

cotton tip applicators for the first 

48 hours. After the first postoperative 

visit, the patient was cleared 

for normal hygiene procedures 

Hoopingarner

Figure 16: Three-month postoperative 

probing shows healthy sulcular depth of 

2 mm 

which included brushing with an 

ultrasoft brush dipped in hot water. 

He was told not to floss around the 

provisional restoration and to avoid 

sticky foods in that area. 

Emergency care contact numbers 

were given. No narcotic analgesics 

were prescribed and the patient 

was instructed to use over-thecounter 

ibuprofen if necessary. 

E. Complications 

There was slight soft tissue invasion 

under the provisional 

restoration. This was removed with 

a 3% hydrogen peroxide scrub. The 

shade of the restoration was a little 

opaque but well within the 

patient’s acceptable expectation 

limits. 

F. Prognosis 

The prognosis for maintenance of 

the restoration is excellent. The 

tissue appeared to be healing 

nicely, giving an expectation of an 

excellent prognosis. The prognosis 

for continued pulpal vitality was 

still somewhat guarded. 

G. Treatment Records 

All appropriate details described 

Hoopingarner 

Figure 17: Three-month postoperative 

periapical radiograph 

above were entered into the 

patient’s record. 

FOLLOW-UP CARE 

A. Assessment of Treatment 

Outcome 

The patient was very pleased with 

the treatment outcome, especially 

since he was seen on an emergency 

basis and treatment was completed 

in a short time frame to meet his 

travel schedule. He reported no 

postoperative pain and the tissues 

showed no sign of inflammation or 

inappropriate pocket depth. No 

deep probing was indicated for 

three months postoperatively. 

B. Complications 

The patient reported no postoperative 

complications. 

C. Long-Term Results 

At 3 months the restoration 

showed no signs of failure and had 

intact margins. The tissues were 

maintaining a good level of health 

with a palatal probing depth of 2 

mm (Figure 16).The periapical 

radiograph (Figure 17) demonstrated 

normal tissue. 

D. Long-Term Prognosis 

Because of the biocompatibility of 

CLINICAL CASE 

the pressed ceramic restoration and 

the exact treatment planning of the 

attachment levels, the long-term 

tissue prognosis remains excellent. 


Dr. Charles Hoopingarner attended 

the University of Texas Health 

Science Center at Houston 

(UTHSCH) Dental Branch, graduating 

with a DDS in 1973. He has 

maintained a private practice in 

Houston, Texas since 1973. He was 

an adjunct associate professor in 

anatomical sciences at UTHSCH 

Dental Branch for 11 years. 

Currently he is adjunct clinical 

faculty in the Restorative Dentistry 

Department at UTHSCH and has 

been a clinical instructor at the Las 

Vegas Institute for Advanced 

Dental Studies since 1997, teaching 

Advanced Anterior Aesthetics and 

Comprehensive Aesthetic 

Reconstruction and Laser 

Dentistry. Dr. Hoopingarner is a 

member of the Academy of Laser 

Dentistry (ALD) and has used 

dental lasers of various wavelengths 

as integral parts of his 

patient care delivery system for the 

last 10 years. He holds Advanced 

and Standard Proficiency certification 

from the ALD and has lectured 

internationally on the safety and 

use of laser technology in the 

dental practice. He may be 

contacted by e-mail at 

choop@swbell.net. 

Disclosure: Dr. Hoopingarner has no 

direct financial or ownership positions 

with commercial companies 

relative to this case presentation. He 

has received honoraria and expenses 

from HOYA ConBio to present material 

on laser dentistry. ■■ 


155


156 

RESEARCH ABSTRACTS 

Editor’s Note: The following eight abstracts are offered as topics of current interest. Readers are 

invited to submit to the editor inquiries concerning laser-related scientific topics for possible 

inclusion in future issues. We’ll scan the literature and present relevant abstracts. 

LASER BACTERICIDAL EFFECTS 

ON INTRAORAL IMPLANTS 

In their article on Er-YAG laser-assisted implant periapical 

lesion therapy (135-141), Dr. Avi Reyhanian and 

Dr. Donald Coluzzi mention the bactericidal potential of 

laser irradiation of implant surfaces. The notion of 

utilizing laser energy to reduce surface bacteria on 

intraoral implants as a means to help ensure successful 

osseointegration and reduce the incidence of periimplantitis 

has been studied by a number of 

researchers investigating a variety of wavelengths, 

including excimer, diode, Nd:YAG, erbium, and carbon 

dioxide lasers. Abstracts from a sampling of published 

papers representing various wavelengths appear below. 

Most researchers to date have investigated the antimicrobial 

effect, primarily due to heat generated by various 

lasers, on implant surfaces in in vitro experiments. 

Heinrich and colleagues take a different approach: use a 

KrF excimer (248 nm) laser to promote mucosal adhesion 

as a biological barrier against bacterial infection. Another 

group (Dörtbudak et al.) studied the effects of “soft” diode 

laser exposure on implants in patients. 

Overall, results are mixed. Certain lasers do appear 

to have bactericidal potential on selected microorgan- 

isms on certain types of implants under certain conditions. 

Questions regarding the relative efficacy of laser 

vs. conventional treatment remain, as do concerns 

related to potential alteration of implant surface 

morphology, thermal damage to adjacent tissues, and 

inability to reestablish the biocompatibility of contaminated 

surfaces. Nevertheless, the potential for laser 

application in promoting long-term implant success via 

bacterial reduction exists. Further study is warranted, 

especially to determine effectiveness and safety in a 

clinical environment, with special emphasis placed on 

appropriate parameter settings and duration of laser 

exposure. 

For U.S. readers, no laser has been cleared by the 

U.S. Food and Drug Administration for “decontaminating” 

or inducing bactericidal effects on intraoral 

implants. 

As always, clinicians are advised to review the 

specific indications for use of their lasers and to review 

their operator manuals for guidance on operating 

parameters before attempting similar techniques on 

their patients.


LASER-MODIFIED TITANIUM IMPLANTS FOR IMPROVED CELL ADHESION 

Andreas Heinrich, Katrin Dengler, Timo Koerner, Cornelia Haczek, 

Herbert Deppe, and Bernd Stritzker 

Concerning dental implant systems, a main problem is 

the adhesion of peri-implant mucosa in the cervical 

region. The aim of the present study was to use a laser 

for modifying titanium implants to promote mucosal 

adhesion, which is indispensable as a biological barrier 

against bacterial infection. By the use of a KrF excimer 

laser, it was possible to induce a holey structure on the 

polished area of the implant surface, which was 

analysed by a scanning electron microscope. In addi- 

Universität Augsburg, Augsburg, Germany 

Lasers Med Sci 2007 Apr 28; [Epub ahead of print] 10.1007/s10103-007-0460-z 

tion, the attachment of fibroblast cells to the created 

structures was investigated with the aid of an environmental 

scanning electron microscope. It turned out that 

the cells preferentially attach to the holey structure. 

Thereby, the cells form bridges inside, leading to a 

complete covering of the hole. In this way, a more effective 

biological barrier against bacteria can be created. 

Copyright 2007 Springer 

LETHAL PHOTOSENSITIZATION FOR DECONTAMINATION OF IMPLANT 

SUR FA CES IN THE TREATMENT OF PERI-IMPLANTITIS 

Orhun Dörtbudak, Robert Haas, Thomas Bernhart, Georg Mailath-Pokorny 

Peri-implantitis is considered to be a multifactorial 

process involving bacterial contamination of the 

implant surface. A previous study demonstrated that a 

combination of toluidine blue O (100 microgram/ml) 

and irradiation with a diode soft laser with a wavelength 

of 905 nm results in an elimination of 

Porphyromonas gingivalis (P. gingivalis), Prevotella 

intermedia (P. intermedia), and Actinobacillus actinomycetemcomitans 

(A. actinomycetemcomitans) on 

different implant surfaces (machined, plasma-flamesprayed, 

etched, hydroxyapatite-coated). The aim of this 

study was to examine the laser effect in vivo. In 15 

patients with IMZ implants who showed clinical and 

radiographic signs of peri-implantitis, toluidine blue O 

University of Vienna, Vienna, Austria 

Clin Oral Implants Res 2001;12(2):104-108 

was applied to the implant surface for 1 min and the 

surface was then irradiated with a diode soft laser with 

a wavelength of 690 nm for 60 s. Bacterial samples 

were taken before and after application of the dye and 

after lasing. The cultures were evaluated semiquantitatively 

for A. actinomycetemcomitans, P. gingivalis, and 

P. intermedia. It was found that the combined treatment 

reduced the bacterial counts by 2 log steps on 

average. The application of TBO and laser resulted in a 

significant reduction (P < 0.0001) of the initial values 

in all 3 groups of bacteria. Complete elimination of 

bacteria was not achieved. 

Copyright 2001 Blackwell Publishing and the European 

Association for Osseointegration 


157


158 


ANTIMICROBIAL EFFICACY OF SEMICONDUCTOR LASER 

IRRADIATION ON IMPLANT SURFACES 

Matthias Kreisler, Wolfgang Kohnen, Claudio Marinello, Jürgen Schoof, 

Ernst Langnau, Bernd Jansen, Bernd d’Hoedt 

Purpose: This study was conducted to investigate the 

antimicrobial effect of an 809-nm semiconductor laser on 

common dental implant surfaces. Materials and Methods: 

Sandblasted and acid-etched (SA), plasma-sprayed (TPS), 

and hydroxyapatite-coated (HA) titanium disks were 

incubated with a suspension of S. sanguinis (ATCC 

10556) and subsequently irradiated with a galliumaluminum-arsenide 

(GaAlAs) laser using a 600-microm 

optical fiber with a power output of 0.5 to 2.5 W, corresponding 

to power densities of 176.9 to 884.6 W/cm 2 . 

Bacterial reduction was calculated by counting colonyforming 

units on blood agar plates. Cell numbers were 

compared to untreated control samples and to samples 

treated with chlorhexidine digluconate (CHX). Heat 

development during irradiation of the implants placed in 

bone blocks was visualized by means of shortwave thermography. 

Results: In TPS and SA specimens, laser 

irradiation led to a significant bacterial reduction at all 

power settings. In an energy-dependent manner, the 

Microbiologic examinations of implants have shown that 

certain microorganisms described as periodontal 

pathogens may have an influence on the development 

and the progression of peri-implant disease. This experimental 

study aimed to examine the bactericidal effect of 

irradiation with a soft laser on bacteria associated with 

peri-implantitis following exposure to a photosensitizing 

substance. Platelets made of commercially pure titanium, 

either with a machined surface or with a hydroxyapatite 

or plasma-flame-sprayed surface or with a corundumblasted 

and etched surface, were incubated with a pure 

suspension of Actinobacillus actinomycetemcomitans or 

Porphyromonas gingivalis or Prevotella intermedia. The 

surfaces were then treated with a toluidine blue solution 

Johannes Gutenberg University, Mainz, Germany 

Int J Maxillofac Implants 2003;18(5):706-711 

number of viable bacteria was reduced by 45.0% to 99.4% 

in TPS specimens and 57.6% to 99.9% in SA specimens. 

On HA-coated disks, a significant bacterial kill was 

achieved at 2.0 W (98.2%) and 2.5 W (99.3%) only (t test, 

P < .05). For specimens treated with CHX, the bacterial 

counts were reduced by 99.99% in TPS and HA-coated 

samples and by 99.89% in SA samples. Discussion: The 

results of the study indicate that the 809-nm semiconductor 

laser is capable of decontaminating implant 

surfaces. Surface characteristics determine the necessary 

power density to achieve a sufficient bactericidal effect. 

The bactericidal effect, however, was lower than that 

achieved by a 1-minute treatment with 0.2% CHX. The 

rapid heat generation during laser irradiation requires 

special consideration of thermal damage to adjacent 

tissues. Conclusion: No obvious advantage of semiconductor 

laser treatment over conventional methods of 

disinfection could be detected in vitro. 

Copyright 2003 Quintessence Publishing Co., Inc. 

ELIMINATION OF BACTERIA ON DIFFERENT IMPLANT SURFACES THROUGH 

PHOTOSENSITIZATION AND SOFT LASER: AN IN VITRO STUDY 

Robert Haas, Orhun Dörtbudak, Nikoletta Mensdorff-Pouilly, Georg Mailath 

University of Vienna, Vienna, Austria 


and irradiated with a diode soft laser with a wavelength 

of 905 nm for 1 min. None of the smears obtained from 

the thus-treated surfaces showed bacterial growth, 

whereas the smears obtained from surfaces that had 

been subjected to only one type of treatment showed 

unchanged growth of every target organism tested (P < 

0.0006). Electron microscopic inspection of the thustreated 

platelets revealed that combined dye/laser 

treatment resulted in the destruction of bacterial cells. 

The present in vitro results indicate that lethal photosensitization 

may be of use for treatment of peri-implantitis. 


Association for Osseointegration


EFFECTS OF THE ND:YAG DENTAL LASER ON PLASMA-SPRAYED 

AND HYDROXYAPATITE-COATED TITANIUM DENTAL IMPLANTS: 

SURFACE ALTERATION AND ATTEMPTED STERILIZATION 

The Nd:YAG dental laser has been recommended for a 

number of applications, including the decontamination 

or sterilization of surfaces of dental implants that are 

diseased or failing. The effects of laser irradiation in 

vitro (1) on the surface properties of plasma-sprayed 

titanium and plasma-sprayed hydroxyapatite-coated 

titanium dental implants, and (2) on the potential to 

sterilize those surfaces after contamination with spores 

of Bacillus subtilis have been examined. Surface effects 

were examined by scanning electron microscopy, energy 

dispersive spectroscopy, and X-ray diffraction after 

laser irradiation at 0.3, 2.0, and 3.0 W using either 

contact or noncontact handpieces. Controls received no 

Titanium platelets with a sand-blasted and acid-etched 

surface were coated with bovine serum albumin and 

incubated with a suspension of Porphyromonas gingivalis 

(ATCC 33277). Four groups with a total of 48 specimens 

were formed. Laser irradiation of the specimens (n = 12) 

was performed on a computer-controlled XY translation 

stage at pulse energy 60 mJ and frequency 10 pps. 

Twelve specimens were treated with an air powder 

system. After the respective treatment, human gingival 

fibroblasts were incubated on the specimens. The proliferation 

rate was determined by means of fluorescence 

activity of a redox indicator (Alamar Blue Assay) which is 

reduced by metabolic activity related to cellular growth. 

Proliferation was determined up to 72 h. Contaminated 

and nontreated as well as sterile specimens served as 

positive and negative controls. Proliferation activity was 

Carl M. Block, John A. Mayo, Gerald H. Evans 

Louisiana State University Medical Center, New Orleans, Louisiana 

Int J Oral Maxillofac Implants 1992;7(4):441-449 

IN VITRO EVALUATION OF THE BIOCOMPATIBILITY OF 

CONTAMINATED IMPLANT SURFACES TREATED WITH 

AN ER:YA G LA SER AND AN AIR POWDER SY STEM 

Matthias Kreisler, Wolfgang Kohnen, Ann-Babett Christoffers, Hermann Götz, Bernd Jansen, 

Heinz Duschner, Bernd d’Hoedt 

Johannes Gutenberg-University Mainz, Mainz, Germany 


laser irradiation. Melting, loss of porosity, and other 

surface alterations were observed on both types of 

implants, even with the lowest power setting. For the 

sterilization study, both types of implants were first 

sterilized by exposure to ethylene oxide and then 

contaminated with spores of B. subtilis. After laser irradiation, 

the implants were transferred to sterile growth 

medium and incubated. Laser irradiation did not sterilize 

either type of implant. The spore-contaminated 

implants in the control group were successfully sterilized 

with ethylene oxide. 

Copyright 1992 Quintessence Publishing Co., Inc. 

significantly (Mann-Whitney U-test, P < 0.05) reduced on 

contaminated and nontreated platelets when compared 

to sterile specimens. Both on laser as well as air powdertreated 

specimens, cell growth was not significantly 

different from that on sterile specimens. Air powder 

treatment led to microscopically visible alterations of the 

implant surface whereas laser-treated surfaces remained 

unchanged. Both air powder and Er:YAG laser irradiation 

have a good potential to remove cytotoxic bacterial 

components from implant surfaces. At the irradiation 

parameters investigated, the Er:YAG laser ensures a reliable 

decontamination of implants in vitro without 

altering surface morphology. 


Association for Osseointegration 


159


160 


INFLUENCE OF AN ERBIUM, CHROMIUM-DOPED YTTRIUM, 

SCANDIUM, GALLIUM, AND GARNET (ER,CR:YSGG) LASER 

ON THE REESTABLISHMENT OF THE BIOCOMPATIBILITY 

OF CONTAMINATED TITANIUM IMPLANT SURFACES 

Frank Schwarz, Enaas Nuesry, Katrin Bieling, Monika Herten, Jürgen Becker 

Background: The aim of the present study was to evaluate 

the influence of an erbium, chromium-doped 

yttrium, scandium, gallium, and garnet (Er,Cr:YSGG 

laser [ERCL]) on (1) the surface structure and biocompatibility 

of titanium implants and (2) the removal of 

plaque biofilms and reestablishment of the biocompatibility 

of contaminated titanium surfaces. Methods: 

Intraoral splints were used to collect an in vivo 

supragingival biofilm on sand-blasted and acid-etched 

titanium disks for 24 hours. ERCL was used at an 

energy output of 0.5, 1.0, 1.5, 2.0, and 2.5 W for the 

irradiation of (1) noncontaminated (20 and 25 Hz) and 

(2) plaque-contaminated (25 Hz) titanium disks. 

Unworn and untreated nonirradiated, sterile titanium 

disks served as untreated controls (UC). Specimens 

were incubated with SaOs-2 osteoblasts for 6 days. 

Treatment time, residual plaque biofilm (RPB) areas 

(%), mitochondrial cell activity (MA) (counts per 

B ACTERICIDAL EFFICACY OF CARBON DIOXIDE LASER 

AGAINST BACTERIA-CONTAMINATED TITANIUM IMPLANT AND 

SUBSEQUENT CELLULAR ADHESION TO IRRADIATED AREA 

Background and Objective: The aim of this study was to 

assess CO 2 laser ability to eliminate bacteria from titanium 

implant surfaces. The changes of the surface 

structure, the rise in temperature, and the damage of 

connective tissue cells after laser irradiation were also 

considered. Study Design/Materials and Methods: 

Streptococcus sanguis and Porphyromonas gingivalis on 

titanium discs were irradiated by an expanded beam of 

CO 2 laser. Surface alteration was observed by a light, 

and a scanning electron, microscope. Temperature was 

measured with a thermograph. Damage of fibroblastic 

(L-929) and osteoblastic (MC3T3-E1) cells outside the 

Heinrich Heine University, Düsseldorf, Germany 

J Periodontol 2006;77(11):1820-1827 

Taku Kato, Haruka Kusakari, Etsuro Hoshino 

Niigata University, Niigata, Japan 

Lasers Surg Med 1998;23(5):299-309 

second), and cell morphology/surface changes (scanning 

electron microscopy [SEM]) were assessed. Results: (1) 

ERCL using either 0.5, 1.0, 1.5, 2.0, or 2.5 W at both 20 

and 25 Hz resulted in comparable mean MA values as 

measured in the UC group. A monolayer of flattened 

SaOs-2 cells showing complete cytoplasmatic extensions 

and lamellopodia was observed in both ERCL and 

UC groups. (2) Mean RPB areas decreased significantly 

with increasing energy settings (53.8 +/- 2.2 at 0.5 W to 

9.8 +/- 6.2 at 2.5 W). However, mean MA values were 

significantly higher in the UC group. Conclusion: 

Within the limits of the present study, it was concluded 

that even though ERCL exhibited a high efficiency to 

remove plaque biofilms in an energy-dependent 

manner, it failed to reestablish the biocompatibility of 

contaminated titanium surfaces. 

Copyright 2006 The American Academy of Periodontology 

irradiation spot and adhesion of the cells to the irradiated 

area were also estimated. Results: All the 

organisms (108) of S. sanguis and P. gingivalis were 

killed by the irradiation at 286 J/cm 2 and 245 J/cm 2 , 

respectively. Furthermore, laser irradiation did not 

cause surface alteration, rise of temperature, serious 

damage of connective tissue cells located outside the 

irradiation spot, or inhibition of cell adhesion to the 

irradiated area. Conclusion: CO 2 laser irradiation with 

expanded beam may be useful in removing bacterial 

contaminants from implant surface. 

Copyright 1998 Wiley-Liss, Inc. ■■

Optimizing visualization and ergonomics. - Academy of Laser Dentistry

Create successful ePaper yourself

Delete template?

Save as template?